Radio Exam Sök

a io o
xam
Dentistr
2019
e onar irs c
Leonard Kirscht© Radiology Exam 2019
Bisectin - a n le t echni ue b a s i c ri n c i l e s
ossible mistakes.
1.1. Basic rinci les
• 1. Bisecting — angle technique + variation of periapical x — ray
• 2. Basic principle of bisecting — angle technique + c entral x — ray beam
directed perpendicular to an imaginary line which bisects (divides in half) the
angle formed by long axis of tooth and long axis of film
X~ay
D head
RI
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1.2. Positionin
• 1. Film should be positioned as close to lingual surface as possible and
reproduce length of each root of a multi — rooted tooth + central beam must
be angulated differently for each root
• 2. Patient should close mouth slowly + retain position of film
PROJECTION MAXILLA MANDIBLE FILM
Incisor +40' -15 Vertically
Ca nines +45 -20 Vertically
Premolar +30' 10 Horizontally
Molar +20 50 Horizontally
1.3. Advanta es 8 Disadvanta es
• 1. Advantages
o 1. True imageof tooth length & width
o 2. More comfortable + film placedin mouth at angle to long axis of
teeth
• Doesn't hurt oral tissues as much
• 2. Disadvantages
o 1. More distortion + film & teethat an angle to each other (not parallel!)
o 2. Harderto position X — ray beam
o 3. Film less stable(in mouth)
1.4. Indications
• 1. Shallow hard palate, torus palatinus
• 2. Shallow, sensitive floor of mouth
• 3. Short lingual frenulum
• 4. Impacted wisdom teeth
1.5. Mistakes
• 1. Vertical beam angulation + e l o ngation(smaller angle than perpendicular
(90')) or foreshortening (more than perpendicular angle)
• 2. Horizontal beam angulation + teeth overlap
• 3. Wrongly positioned receptor
• 4. Movement artifacts
2. Paralellin t e c hni u e b a si c ri n c i le s oss i b le

mistakes.
• 1. Paralleling technique + pre f erred m ethod fo r ma k i ng p e r iapical
radiographs
• 2. Film is placed parallel to long axis of tooth
o Mi nimizes image distortion & i ncorporates imaging principles for
image sharpness resolution
• 3. To achieve parallel orientation + position film towards middle of oral cavity
away from teeth
o Al lows teeth & filmto be parallel + but results in image magnification
& loss of sharpness
o Th us + p aralleling technique uses relatively long open — ended cone
to increase focal spot — to — object distance + directs only most central
& parallel rays to film & teeth + r educes image magnification while
increasing sharpness & resolution
2.2. Positionin
• 1. Film placed parallel to long axis of tooth
• 2. Central beam of X — ray + goes perpendicular (90') against film & long axis
of tooth
• 3. Make sure patient has bite holder stabilized 1
o Co tton rollsused in places of missing teeth I
• 4. If holders with ring used + ring as close to face as possible

2.3. Possible mistakes

• 1. Poor film placement
o In correct anterior — posterior positioning(too far or too close to teeth)
• 2. Patient instruction
o If patientis not completely closing mouth & biting on holder + roots
cut off
• 3. Cone cutting
o Oc curswhen part of film not covered by x — ray beam + use paralleling
instrument to align beam with film
• 4. Overlap
o Wr ong horizontal angulation
• ( 5 . Rest + see mistake questions)
3. Bitewin X — ra s indications.
• 1. BW (bitewing or interproximal) image + includes crowns of mandibular &
maxillary teeth and alveolar crest
• 2. If full set of teeth + 2 BW on each side (one may be enough if teeth missing)
o 1. Premolar
0
o 2. Molar (3' and no 3'd molar)
3.2. Mistakes
1. Overlap of contact points (wrong horizontal angulation)
2. Wrong placement of film + not all regions of interest covered
3. 'Cone cutting' + wrong beam aiming
4. Movement artifacts
5. Reverse placement of film
3.3. Indications 8 Inter retation

1. Caries diagnostics
o 1. Enamel
o 2. Dentin
• 1. Occlusal!!
• 2. Buccal, lingual (detect it clinically)
• 3. Roots
• 4. Secondary
• 5. Cervical burnout artifact
2. Secondary caries
3. Evaluation of Periodontium (level of alveolar bone crest)
o He althy periodontium
• 1. Cortical border of alveolar process
• 2. Alveolar bone level 1 — 1.5mm from CEJ
• 3. Alveolar bone level parallel to line drawn between CEJ of both
teeth
• 4. Bone between front teeth + sharpen shape
4. Calculus
5. Evaluation of exisiting restorations (fillings, crowns etc.)
o 1. Overhangs
o 2. Gap
o 3. Fractures
4. Peria ical X — ra s indications.

• 1. PA + taken to visualize root+ surrounding periodontium
• 2. Can be taken of any tooth + used to determine cause of pain in specific
tooth (pulpitis, apical periodontitis)
• 3. Paralleling technique or bi s ecting angle technique can b e ch o sen
(depending on case)
4.2. Indications
• 1. Periapical lesions, inflammation, pathologies
• 2. Periodontal status
• 3. Trauma to teeth and surrounding tissue
• 4. Impacted teeth
• 5. Root morphology before extraction
• 6. Endodontics
• 7. Evaluation of implants
5. Occlusal X — ra s indications.
5.1. Occlusal techni ue UPPER aw
• 1. Patient's head + occlusal plane parallel to floor
• 2. Film with white side up placed onto mandibular teeth (occlusal surfaces) +
patient slightly bites film
• 3. X — ray tube positioned over patient's midline through nose in 65' — 70'
against film
5.2. Occlusal techni ue LOWER aw

• 1. Film with white side down + in middle of oral cavity on occlusal surfaces of
mandibular teeth + patient slightly bites
• 2. Patient tilts his head back as far as possible + fixates it
• 3. X — ray tube placed under patient's chin in center of imaginary line which
connects lower 1" molars and 90' angle against film
65
5.3. Indications
• 1. Evaluation of periodontium for adults and children with gag reflex
• 2. Teeth trauma
• 3. Retained teeth and lesions in hard palate
• 4. Salivary stones in salivary glands
• 5. Retained teeth in mandible
• 6. Expansion of lesions
6. Processin ste s of an X — ra film

6.1. Di ital X — ra
• 1. More time efficient
• 2. Image transferred to computer instantly by wired sensor + p r ocessed
through software + appears on screen
• 3. Great advantage + image manipulation
o 1. Change color, contrast, size + better analysis
o 2. Safe storageof pictures
o 3. Far less radiation exposurethan conventional radiology
6.2. Conventional X — ra
• 1. Two components + emulsion & base
o 1. Emulsion + crystalsof silver bromide
• 1. Sensitive to x — rays & visible light + records radiographic
image
• 2. Can cover either both or just one side of film
• 1. If only one side + has zit (Pumpinje)
• 2. Emulsion — covered side must be against tooth
surface
• 2. Steps
o 1. Development
• Sensitized silver halide crystals in emulsion + converted to
black metallic silver + produce black/grey parts of image
o 2. Washing
• Film washed in water + remove residual developer solution
o 3. Fixation
• Unsensitized silver halide crystals in emulsion + removed +
reveal transparent/white parts of image; emulsion hardened
o 4. Washing
• Film washed thoroughly in running water + remove residual
fixer solution
o 5. Drying
• Resulting black/white/grey radiograph is dried
7. Infection control in dental radiolo

7.1. Contamination
1. Primary goal of infection control + p revent cross — contamination btw.
patients and dental staff
o Po tentialfor cross — contamination is great!
2. Operator's hands may become contaminated by contact with patient' s
mouth and saliva — contaminated films/film holders
3. Operator then must touch/adjust X — ray tube head & machine control to
make exposure etc.
4. Each dental office + s h ould have written policy describing infection
control!
7.2. Universal recautions

1. Wear gloves during ALL radiographic procedures
2. Disinfect & cover x — ray machine, working surfaces & chair
3. Sterilize non — disposable instruments
4. Use barrier — protected film (sensor) or disposable container
5. Prevent contamination of processing equipment
7.3. Ste s of infection control

1. Patient seated
2. Wash hands
3. Choose film holder+ film
4. Place film into holder
5. Put on gloves
6. Thyroid shield for patient
7. Choose right parameters for exposition, place film into patient's mouth aim
beam tube, make exposition
8. Take film out of patient's mouth; ask patient to wait outside
9. Film placed on paper tissue + disinfected with surface disinfectant; holder
is rinsed under running water and placed into disinfectant liquid
10. Return to workplace + disinfect tube head, control panel, chair, thyroid
shield
11. Take off gloves
12. Place film into developer
13. Do not walk around with gloves on!
8. Paranasal sinuses radiolo ical methods dia nostic

informativit in intraoral and anoramic radio ra hs.
8.1. Paranasal sinuses and their radiolo ical methods
• 1. Paranasal sinuses = air — filled cavities of craniofacial complex
o 1. Nlaxillary
o 2. Frontal
o 3. Ethmoidal
o 4. Sphenoidal
• 3. Radiographic methods
o 1. Periapical/panoramic radiograph
o 2. Water projection
• 1. Optimal for vi sualization of ma xillary, frontal, ethmoidal
sinuses + compare internal radiopacities/air cells
• 2. If made with mouth open + parts of sphenoidal sinus visible
o 3. Submentovertex view
• Evaluation of lateral + posterior borders of maxillary sinus +
ethmoidal air cells
o 4. Caldwell view
• Evaluation frontal sinuses + ethmoidal air cells
o 5. Lateral skull view
• Examination of all four pairs of paranasal sinuses
• 4. CT & MRI examination
o 1. Replaced plane radiography+ conventional tomography
o 2. Provide multiple sectionsthrough sinuses in different planes
o 3. N l ost r evealing techniquesfor pa r anasal sinuses + adjacent
structures/areas
o 4. CT
• 1. Extent of disease (chronic/recurrent sinusitis)
• 2. Coronal CT + visualization of ostiomeatal complex + nasal
cavities + showing any reaction in surrounding tissue of sinus
disease
o 5. N IRI
• Superior visualization of soft tissues/surrounding soft tissues or
differentiation of re tained fluid secretions from soft t issue
masses in sinuses
Water view
• • •
Caldwell view
• •
3 1
Submentovertex view
5
8 .2. Dia nostic informativit i n intraoral and a n o ramic radio ra h s

• 1. Can appear on radiographs for dental purposes (e.g. maxillary periapical,
occlusal or panoramic) or for orthodontic/orthognatic surgical purposes + but
not necessarily in diagnostic way
• 2. Periapical
o Provides detailed, however limited view of alveolar recess + floor of
maxillary antrum
o If a b n ormality of s i nus i s s u s pected + m a x i l lary lateral occlusal
projection can be made + more extensive view
• 3. Panoramic radiograph
o Shows both maxillary sinuses + r eveals greater internal structure +
parts of inferior+ posterior+ anteromedial walls
9 . Dia nostic i m a i n of t e r n o r o m andibular o i n t

dia nostic informativit .
9 .1. Dia nostic ima i n o f T MJ
• 1. TMJ + most difficult areas to investigate (radiographically)
o Consider normal anatomy, type of imaging technique:
• 1. Clinical indications
• 2. How investigation is performed
• 3. Clinical information provided
• 4. Limitations & disadvantages of method
• 5. Radiographic features of more common pathologies of the
joints
• 2. Methods
o 1. X — ray
• 1. Standard projections
• Submentovertex, lateral oblique, transcranial (open/closed
mouth), transmaxillar (closed mouth)
• 2. Individual projctions, panoramic X — ray, skull x — ray
o 2. Arthroscopy, X — ray arthography
o 3 . CT/MRI
o 4. Ultrasonography
Upper synovial
cavity
Postglenoid Articular
process eminence
Joint disc
Blood vessels
Lower synovial
cavity
Condyle
Lateral pterygoid muscle

9 .2. Dia nostic informativit /main disease affectin T M J + th e i r

radio ra hic features
• 1. Developmental
o 1 . Cond larh e r la s i a
• 1. Asymmetric, large condyle
o 2 . Cond larh o la s i a
• 1. Diminished in size but proportional condyle, neck & fossa
• 2. Unilateral
~3. • lfld d
• 1. Depression/notch in middle of condylar head; depression from
flat to very deep
• 2. Incidental finding
• 2. Disc displacement pathologies
o 1. When clinical features recognized + radiological investigation used
(if required)
o 2. Radiographic findings:
• 1. Disc displacement
• 2. Disc reduction & non — reduction
• 3. Disc deformation & perforation
• 4. Fibrous adhesion
• 5. NIRI + radiological method of choice!
• 3. Remodelling & Inflammatory
~l. R d Ill
• 1. Adaptive response of cartilage + bone to force applied to joint
+ leads to alteration in shape of condyle + articular eminence
• 2. Radiographic findings
• S urface flattening, thickened cortical bone, s u b
chondral sclerosis
o 2. De enerative'ointdisease Osteoarthritis
•
1. Degenerative changes of cartilaginous & bony structures
when joint's remodeling capacity has ceased; any age b u t
increases with age
• 1. Surface erosion
• 2. Decrease in size of condyle due to erosion/destruction
• 3. Sub — chondral cyst
• 4. Narrow joint space
• 5. Osteophytes break off + leads to free standing calcified
structures in joint
o 3. Rheumatoid arthritis
• 1. Systemic disease + a ff ects synovial membrane of joints
(symmetrically)
•
2. Radiographic findings
• Resorption of bony structures, anterior open bite can
occur
• 2. Sub — chondral cysts, sclerosis
• 3. Surface flattening
• 4. P ossible ankyloses
o 4. Juvenile idio athic arthritis JIA
• 1. Auto — immune disorder; affects different large joints of body;
uni — or bilateral + b i r d f ac e may d evelop due to condylar
resorption + posterior — inferior rotation of mandible
• 1. E a r ly i nflammatory changes before bone resorption
occuI s
• 2. Bony structures
o 1. Condyle deformation
o 2. Shallow & wide fossa
o 3. Erosion
o 4. Total resorption of condyle+ neck can occur
• 4. S ynovial chondromatosis
o 1. Synovial membrane and/or cartilage structures + calcified
o 2. Radiographic findings
• 1. Multiple calcified, free — standing structures around condyle
• 2. Structures usually have cortex
• 3. Differentiate from chondro — / osteosarcoma
• 5. Trauma
o Radiographic findings
• Condylar fracture, processus condylaris fracture
• 6. Ankyloses
o 1 . C o n dylar m o vement r e stricted due t o f u s io n o f i n t r aarticular
components
o 2. Bony ankylosis
• C ondyle or r amus a ttracted to t e mporal/zygomatic bone b y
osseous bridge
o 3. Fibrous ankylosis
• Fibrous tissue creates union of joint components
o 4. Radiographic findings
• 1. Irregular joint surfaces
• 2. Very narrow joint space
• 3. Joint surfaces fits to each other in 'jigsaw pattern'
• 7. Tumor (benign/malignant)
o 1. Rare!
o 2. Difficult to differentiate
o 3. Benign + osteochondroma, osteoma
o 4. Malignant + sarcomas
10. Panoramic r a diolo indications d i a n o stic

informativit .
10.1. Panoramic radiolo
• 1. Technique for producing single tomographic image of facial structures +
includes maxillary & m a n dibular dental arches an d t h e ir su p porting
structures
• 2. This is a curvi — linear variant of conventional tomography; based on
principle of reciprocal movement of X — ray source and an image receptor
around central point/plane called 'image layer' (object of interest is located here)
o Ob jectsin front or behind this image layer + not clearly captured
10.2. Indications
• 1. Before orthodontic treatment
• 2. Evaluation of new f ormings (malignant/benign masses) in jaws and/or
unerupted teeth + can't be seen in intraoral pictures
• 3. Periodontal examination
• 4. Localization of wisdom teeth before extraction
• 5. Finding mandibular fractures
• 6. Finding pathologies in maxillary sinus
• 7. TMJ comparison
• 8. Implant treatment planning
10.3. Advanta es 8 Disadvanta es dia nostic informativit

• 1. Advantages
o 1. Wide field + goodas overview X — ray
o 2. C a n be ma de if pa t ient cannot open mouth (trauma, fracture,
inflammation)
o 3. Positioningis simple
o 4. Good examination before orthodontic treatment
o 5. Good techniqueto compare both condyles
o 6. Radiation dosage relatively low + approx. 1/3of full mouth series of
PAs
o 7. Limitationof examined field
• 2. Disadvantages
o 1. Cannot see structuresthat are not in focal plane
o 2. Soft tissue shadows + may overlap hard tissue shadows
o 3. Ghost shadows + may overlap structurein focal plane
o 4. Picture + 1.3x bigger than real life size
o 5. Not suitablefor patients below 5 y. o. or mental disordered patients
11. Panoramic radiolo - ositionin m i s takes

• 1. Antero — osterior error
o 1. Patient positioned too much forwards + too close to film
o 2. Patient positioned too much backwards + too far away from film
Too far backwards + too far away from film +

teeth magnified & widened
• 2. Horizontal error
o Patient rotated + mid — sagittal light marker incorrect
•\
Patient rotated to the LEFT +
LEFT molars CLOSER to film + SMALLER
RIGHT molars further away from film + LARGER

• 3. Vertical errors
o 1. Head+ chin tipped down, Frankfort plane not horizontal + occlusal
plane distorted + 'smiley face'
o 2. Head+ chin raised upwards, Frankfort plane not horizontal +

occlusal plane distorted + 'grumpy face'
• 4. Air shadow
o Failure to instruct patient to press tongue against hard palate
• 5. Movement artefact
o Failure to instruct patient to keep still
12. Radiolo ical si ns ofbeni n tumors in aws.

• 1. Radiological features + important to diagnose benign/malignant tumor
o 1. Location
• Where tissue of tumor's origin is normally localized
o 2. Shape + periphery
• Smooth, well defined, sometimes corticated borders, sometimes
incapsulated
o 3. Internal structures
• From total radiolucency to total radiopaque
• 2. Growth
o 1. B e n ign t umors usually expand bone + dislocate anatomical
structures (teeth, mandibular canal etc.)
o 2. Relativelyslow growing
o 3. Possibilityof bone to create new bone + expansion of bone occurs
• 3. Classification of benign tumors which can appear in jaws:
o 1. Hyperplasia(Tori)
• 1. Palatal tori
• 2. Mandibular tori
• 3. Different location + exostoses
• 4. Enostosis (dense bone island)
o 2. Odontogenic tumors
• 1. Ameloblastoma
• 2. Odontoma
• 3. Odontogenic myxoma
• 4. Benign cementoblastoma
o 3. Non — odontogenic tumors
13. Radiolo ical si ns of mali nant tumors in aws.

• 1. Malignant tumors + rare
• 2. Role of radiology in malignant tumors
o 1. Initial diagnosis + first one to detect tumor
o 2. Spread of lesion
o 3. Size & Location of lesion
• 3. Radiologic features (malignant tumors have common features)
0 1 . P eri h e r + Sha e
• 1. ill — defined borders + LACK of cortical border+ capsulation!
• Co m p ared to benign tumors
• 2. Associated with non — healing soft tissue ulceration and/or
swelling + highly suggestive
• 3. Shape is IRREGULAR
0 2. Internal structure
• 1. Most m a l ignancies + do NO T p r o d uc e b o n e/stimulate
formation of reactive bone + radiolucency inside
• Lesions like osteosarcoma + p r o d uce frank sclerosis;
tumors like prostate / breast can induce bone formation
o 3 . Effects on surroundin t i s s u e
• 1. ill — defined, invasive borders/growth
• 2. Destruction of:
• 1. B one
• 2. Cortical borders of anatomical structures
• 3. Lamina dura etc.
• 4. Soft tissue mass
• 3. PDL irregular widening
• 4. Growth along PDL
• 5. Destruction of bone at apicis; displacement of teeth
• Ma y mimic apical periodontitis!
• 6. Teeth seem to 'float in air' due to bone destruction
o 4. Cortical bone destruction appearances

• 1. Cortical bone destruction without periosteal reaction
• No smooth borders
• 2. Laminated periosteal reaction (onion skin reaction) + cortical
bone destruction
• 3. Codman triangle (outer border, marked)
• N e w s u bperiosteal bone + fo r m s wh e n le s ion l ifts
periosteum away from bone + s m a ll t riangle seen at
advancing margin of lesion
• 2. Main causes for Codman triangle:
o 1. Osteosarcoma
o 2. Ewing's Sarcoma
o 3. Subperiosteal abscess(no malignant tumor!)
• 4. Sunray periosteal reaction
1 4. SLOB rule an d s e a r ation o f r o o t c a nals i n

endodontic radiolo
14.1. Endodontic radiolo
• 1. Receptor holder
o Di fferent shapesof holders; usually endodontic 'bite' holder is used
• 2. Rubber dam is on teeth
• 3. Beam projection for multi — rooted / canaled teeth + 'beam shift'
o 1. To see ALL canalsof multi — rooted teeth + beam must be angulated
in horizontal plane:
• 1. 20' mesially for maxillary premolars
• 2. 20' mesially OR distally for maxillary molars
• 3. 20' distally for mandibular molars
• 4. Beam shift
o 1. Advantages
• Identification of overlapping canals + structures
• 1. Unidentified/missed canals
• 2. Facio — lingual localization
o Wh ich is lingually and which is facially? + S LOB
rule
• 3. Curved canals
• 4. Calcified canals
o 2. Disadvantages
• 1. Blurred, unclear image
• 5. Localization of fistula
o 1. To determine origin of fistula + Gutta percha (no. 30 — 40) isinserted
into fistula and X — ray is taken+ fistulography
o 2. Same way depthof periodontal defects can be evaluated
o 3. Local anesthesiais required
14.2. SLOB rule / Parallax/ Ob ect localization

• 1. Parallax
o Is a displacement or difference in the apparent position of an object
viewed along two different lines of sight
• 2. SLOB (Same Lingual Opposite Buccal)
o 1. 2 radiographs are needed!
• 1. First is perpendicular
• 2. 2" is shifted to distal or mesial (20')
o 2. There mustbe a change in the horizontal (or vertical) angulation of
the beam + provides movement of object on image
o 3. HORIZONTAL tube shift
• 1. If tube is moved NIESIALLY + beam is directed more distally
(from mesial)
• 2. If tube is moved DISTALLY + beam is directed more mesially
(from distal)
o 4. VERTICAL tube shift
• 1. If tube is raised + beam is directed down
• 2. If tube is lowered + beam is directed upwards
VU
Rule of SLOB:
Object which is localized ~lin eall moves same direction as beam comes from; so if beam comes
from distal + lingual object moves distally
Buccal object moves to the opposite side + if beam comes from distal, object moves to mesial
A
• A •
• e • •
e • •
• • e • r
• • • • •
15. Normal radio ra hic anatomic structures in anterior

re ion of maxilla.
1 5.1. Basic terms Q1 5 - 1 9
• 1. Radio acit & Radiolucenc
o 1. Radiopacity + capabilityof substance to hinder or completely stop
passage of x — rays (e.g. bones) + produing LIGHT imageon film
• Called radiopaque (inhibit radiation to pass)
o 2. R adiolucency + c a p ability of materials of relatively low atomic
number to allow most x — raysto pass through them + producing DARK
images on film
• Called radiolucent (allow radiation to pass)
• 2. Tooth structure
o 1. E n amel + m o r e r adiopaque than other tissues + m o s t d ense
substance in body (95% minerals)
o 2. Dentin(75% minerals) + comparableto bone radiolucency
o 3. C e m entum (50% minerals) + s i m i lar to de ntin; no d ifference
radiographically to dentin because contrast is low and cementum layer
is thin
• 3. Cervical burnout
o 1. R adiographs sometimes show diffuse radiolucent areas with ill
defined borders on mesial/distal aspects of teeth in cervical region
o 2. T hese regions appear between edge of enamel cap and crest of
alveolar ridge
• These radiolucent areas result from contrast with adjacent,
relatively opaque enamel + alveolar bone; such radiolucencies
should be anticipated in almost all teath and NOT be confused
with root surface caries (similar appearance)
(ma
FIG.'101 Teeth are composed of pulp(arrowon the second molar), FIG. 102 Cervical burnout caused by overexposure of the lateral
IG. 18esl Amalgam restorations appear completely radiopaque
enamel(orrowon the first molar), dentin (ormwon the second premo. portion of teeth between the enamel and alveolar crest(arrows).
g/laws).
lar), and cementum (usually not visible radiographically),
• 4. Lamina Dura
o 1. Thin, radiopaque layerof dense bone surrounding tooth socket
o 2. Thickerthan surrounding trabecular bone; thickness increases with
increase in amount of occlusal stress
• 5. Alveolar crest
o 1. R adiopaque gingival marginof alveolar process which surrounds
teeth
o 2. Considered normalif it is 1.5mm OR LESS from CEJ
o 3. Shows apical recession with age or periodontal disease
• 6. Periodontal li ament s ace
o Co mposed of collagen + radiolucent space between rootand lamina
dura
A
FIG. 10-6 The lamina dura (orrows) appears as a thin opaque layer of bone around teeth, A, and
around a recent extraction socket, I.
FIG. 10-9 The alveolar crests(arrows) are seen as cortical borders of

the alveolar bone.
FIG. 10-'l0 The periodontal lig ame
nt space(arrows) is seen as a
narrow radiolucency between the tooth root and lamina dura.
15.2. Anatomic structures in anterior maxilla

• 1. Intermaxillary suture
o Ex tendsfrom alveolar crest between central incisors
• 2. Anterior nasal spine
• 3. Nasalfossa & septum
• 4. Incisive (nasopalatine) foramen
• 5. Lateral (incisive) fossa
• 6. Nasolacrimal canal
FIG. 10-17 The anterior nasal spine is seen as an opaque V-shaped FIC. '10-18 The anterior floor of the nasal aperture(orrows)appears
FIG. 10-16 The intennaxillary suture may terminate in a V-shaped projection from the floor of the nasal aperture in the midline(orrow). as opaque lines extending laterally from the anterior nasal spine.
widening(onow) at the alveolar crest.
• '
FIG. 10-aa A, The incisive foramen appean as an ovoid

radioiucency (onows) between the roots of tbe central ind-
sors. 0, Note its borders, which are diffuse but within normal
limits.
FIC. 10-26 The lateral fossa is a diffuse radiolucency (onows) in the

region of the apex of the lateral incisor. It is formed by a depression
in the maxilla at this location.
FIG. 10-28 The nasolacrimal canal (anow) is occasionally seen near

the apex of the canine when steep vertical anguiation is used. Note
the mesiodenssupernum
( erary tooth) superior to the central incisor.
1 6. Normal r a dio ra hi c a n a tomic s t ructures i n

osterior re ion of maxilla.
• 1. Maxilla s i nus antrum of hi hmore
o 1. Air — containing cavity linedby mucous membrane
o 2. Cavity + radiolucent; its borders + radiopaque line
• 2. Z o m atic r o cess
o 1. Extensionof lateral maxillary surface that arises in region of apices in
first+ second molars and serves articulation for zygomatic bone
• 3 . Pte o i d l a t e s
o Me dial + lateral pterygoid plateslie immediately posterior to tuberosity
of maxilla; casting a single radiopaque shadow
Fl( . 10-30 T he inferior border of the maxillary sinus(arrotrirs)appears

aS a thin fadIOlMque line neal the apiCeS Of the maXillary premOlarS FIG.'IO-l> The anterior borderof the maxillar)r sinus(wbite arrows)
and molars. crosses thefloor of the nasal fossa(black orrow).
lo tas»mq»eamo n~ srlT ae® I' .QIR

.Ilaw yallixam srlt mott yllatstal tsbrrrtotq (twtmo) allixam aran FIG. 10-%9 Pterygoid plates (orrorrs) located posterior to the maxil-
.(8) nsbtod nirO rttiw sg»el to (A) nsbtod S»irU rttiw llama rsldaitav sfiup sd yam exit ul lary tuberosity.
17. Normal radio ra hic anatomic structures in anterior

re ion of mandibula.
• 1. Lin ual foramen & S ina Mentalis
o Ti ny opening internal surface of mandible; radiolucent dot (apices of
mandibular incisors); Spina mentalis + radiopacity around LF
• 2. Mental Rid e & Nlental Fossa
o 1. M ental ridge + p r o minenceof cortical bone located on external
surface extending from premolar region to midline & slopes upwards
o 2. Nlental fossa + radiolucent areaabove ridge
'P
FIG. 10%$ Mental ridge (arrows) on the anterior surface of the

mandible, seen as a radiopaque ridge.
FIG. 10-40 The mental fossa is a radiolucent depression on the ante-

rior surface of the mandible(arrows) between the alveolar ridge and
mental ridge.
1 8. Normal r a dio ra hi c a n a tomic s t ructures i n

osterior re ion of mandibula.
• 1. Mental Foramen
o 1. O n e x t ernal surface of ma ndible; opening in re gion of ma nd.
Premolars
• Mental nerves + blood vessels exit through it
• 2. Mandibular Canal
o 1. Tube — like passageextending from mandibular foramen to mental
foramen; contains N. alveolaris inferior + blood vessels
o 2. Radiolucent band outlinedby 2 radiopaque lines of cortical plate
• 3. M loh oid Rid e
o 1. Linear prominenceof bone located on internal surface of mandible
o 2. Radiopaque band; extendingfrom molar region downward+ forward
towards lower border of mand. Symphysis
• 4. SubmandibularGland Fossa
o 1. Depressed area of bone located on internal surface of mandible
o 2. Radiolucent areain molar region; below mylohyoid ridge
• 5. External Obli ue Rid e
o 1. Linear prominenceof bone located on external surface of mandible
extending downwards; continuation of anterior border of ramus
o 2. Radiopaque band; endingin 3' d molar region
• 6. Inferior Border of Mandible
• 7. Coronpid rocess
o 1. Marked prominence of bone on anterior ramus of mandible; appears
on maxillary molars
o 2. S e en as tr i a ngular radiopacity superimposed over/inferior t o
maxillary tuberosity
FIG. 10-$0 Mandibular Canal. A, Arrows denote its radiopaque superior and inferior cortical
borders on periapical view. 0, Cone-beam section through body of mandible demonstrating corticated
FIG. 10%7 The mental foramen(arrow) appears as an oval radiolu- borders of mandibular canal. C, Cone-beam cross-sectional view demonstrating circular mandibular
canal with corticated borders lying adjacent to lingual plate. (0 and C made with 3DX Accuitomo,
cency near the apex of the second premolar. j. Morita.)
BG. 10-$7 submandibular gland fossa (orrosvss indicatedby a Ft c. 40 $8 External oblique ridge (orrosvs), seen as a radiopaque line
Y~"y '4 " ge (o"~~~ rune'ng at the evel o the poorly definedradlolucency and spane uabecular bone betow tfse near the alveolar crest in the mandibular third molar region.
molar apices and above the mandibular canal. mandibular molars.
FIG. 10-59 The inferior border of the mandible(arrows) is seen as a

FIG. 10 60 Coronoid process of the mandible (arrows)superimposed dense, broad radiopaque band.
on the maxillary tuberosity.
19: Radicular and residual c sts. Definition clinical

features radio ra hic features differential dia nosis
treatment.
19.1. Radicular c st
• 1. Definition
o 1. Mostcommon type of cyst in jaws
o 2. Arisefrom non — vital teeth + inflammatory products from non-
vital tooth stimulate epithelial rest cells of Malassez in periodontal
ligament + proliferate and undergo cystic degeneration
• 2. Clinical features
o 1. Often no symptomsunless secondary infections occur
o 2. Large cystsmay cause swelling
• 3. Radiologic features
o 1. Location
• Apex of tooth
o 2. Periphery
• Well defined borders; circular form
o 3. Internal structure
• Radiolucency
o 4. Effects
• Neighboring teeth can be displaced + may cause resorption to
their roots
• 4. Differential diagnosis
o 1. Difficult + may even be impossible to differentiate from apical
granuloma
o 2. Periapical cemental dysplasia
o 3. KOT
o 4. Lateral periodontal cyst
• 5. Treatment
o 1. Extraction
o 2. Endodontic treatment+ apical surgery
o 3. If large cyst + surgical removalor marsupialization
• Recurrence unlikely if cyst been removed completely
Cyst coming
from d12 +
lamina dura
expands from
right side and
then going back
to left side of
Cyst coming from d35; poor endodontic treatment
Cyst from d46 (deep

caries); also
radiolucency around
d26; might develop
into cyst later
19.2. Residual C st
• 1. Definition/development
o Wh en radicular cysthas not been treated correctly (extraction + cleaning
of bone) + residual cystcan develop; found in missing tooth places
o Us ually asymptomatic
o 1. Location
• Missing tooth place
o 2. Periphery
• Well defined borders, corticated borders, circular
• Radiolucency
o 4. Effects
• Neighboring teeth can be displaced + may cause resorption to
their roots
o 1. Solitary bone cavity
o 2. Odontogenic keratocystic tumor
• 5. Treatment
o Su rgical removalor marsupialization (both if cyst is large)
Residual cyst after molar Huge cyst in molar region 4'" quadrant Huge cyst in 3"' quadrant
extraction
20: Denti erous f ollicular c s ts. Definition clinical

treatment.
o Cy st + formsaround crown of unerupted tooth
• Fluid accumulates in layers of reduced enamel epithelium or
between epithelium and crown of unerupted tooth
o 1. Clinically missing tooth + possibly hard swelling; facial asymmetry
o 2. Usually painless
o 1. Location
• Around crown of impacted/retained tooth
o 2. Periphery
• Radiolucency + situated around crown of tooth; attaching to CEJ
o 4. Effects
• 1. Neighboring teeth can be displaced + may cause resorption
to their roots
• 2. Considerably expand bone
o 1. Hyperplastic follicle(difficult to differentiate)
• If there is tooth displacement + follicular space more than 5mm
+ most likely cyst!
o 2. KOT
o 3. Ameloblastic fibroma
o 4. Cystic ameloblastoma
• 5. Treatment
o 1. Surgical removal;with tooth
o 2. If large cyst + marsupializationbefore removal
o 3. Cysticameloblastoma
~l
Dentigerous cyst + d38 is retained; cystic lesion

Dentigerous cyst + d38; crown retained; cystic
situated+ attaching around crown of d38 lesion around crown of tooth
21: Lateral er i o dontal c s ts . D e f inition c l i nical

treatment.
o 1. Arisesfrom epithelial rests in periodontium laterally from root
o 2. Mimics lateral periodontal abscess in case of secondary infection
o Us ually asymptomatic; lessthan 1cm in diameter
o 1. Location
• Mostly mandibula; premolar — incisive region
o 2. Periphery
• Radiolucency
o 4. Effects
• Neighboring teeth can be displaced and may cause resorption of
their roots
o 1. Lateral radicular cyst
o 2. Small odontogenic keratocystic tumor (KOT)
o 3. Mental foramen
• 5. Treatment
o 1. Surgical removal
o 2. Enucleation
Teeth are
vital;
radiolucency
attached to
lateral region
of teeth
22. Sim le bone c s ts. Definition clinical features

radio ra hic features differential dia nosis treatment.
o 1. Cavity within bone + lined by connective tissue
o 2. Not a true cyst + no epithelial lining!
o 3. Il ay be empty or contain fluid
o 1. Usually asymptomatic, sometimes pain/tenderness
o 2. ALL teethinvolved are vital
o 3. 10 — 30 years old
o 4. Il ale > female
o 1. Location
• Usually mandibula; between roots + around
o 2. Periphery
• Well defined borders, slightly corticated borders, smooth also
scalloped; scallope (muschelformig); go between roots
• Usually radiolucent; rarely multi — locular
o 4. Effects
• Usually without effects; rarely + minimal expansion of bone
(large lesions)
o KOT
• 5. Treatment
o Op eningof lesion + curettage + initiates bleeding + healing follows
• Follow up radiographic examinations
Young person; still developing roots of Lesion around d35+ d36; after extraction of d36 + blood gets in +
d47, radiolucency going between roots lesion heals; opening of lesion + letting blood in heals bone
23: Naso alatine d uc t c s t s . D e f inition c l i nical

treatment.
o Fo rms in nasopalatine canal when embryonic epithelial remnants of
nasopalatine duct undergo proliferation + cystic degeneration
o 1. Mostly asymptomatic
o 2. Small swelling posteriorto palatine papilla
o 3. B urning sensation/numbnessover palatal mucosa (cyst pressures
nerve)
o 1. Location
• Localized around nasopalatine duct
o 2. Periphery
• Radiolucency
o 4. Effects
• Can displace roots of central incisors + expand bone in all
directions
o 1. Large openingof duct (6mm or more) + consider/evaluate
dynamics (make x — ray later and see if lesion expands)
o 2. Radicular cystof central incisor
• 5. Treatment
o 1. Enucleation
o 2. Il arsupialization
Roundish Huge;
cysts; well 12mm™
— defined nasopalatine
borders; cyst
periodont
al
ligament
of incisors
clearly
seen
24. Inflammation in aws: e ria ical inflammato

lesions osteom elitis. Definition clinical features
radio ra hie features differential dia nosis
treatment.
24.1. Peria ical inflammato l e s ions
o 1. Always dueto necrotic pulp
o 2. Locatedin periapical region of bone (around apex)
o 3. Caries/Trauma + bacteria getinto pulp + out on apex + bone
destruction due to inflammation
• Bone destruction + has emptiness in center (radiolucent);
around it more radiopaque bone (doesn't spread infection as
easy)
o 1. Acute apical periodontitis + painon biting/percussion
o 2. Chronic apical periodontitis + no pain
o 1. Location
• Around apex of tooth
o 2. Periphery
• ill defined
• Usually radiolucent; depends on how long lesion is present
o 4. Effects
• Resorption of cortical bone present + causes periosteal action
o 5. Visibility
• 1. Chronic processes are visible; acute usually not visible on x
— ray
• 2. Acute (early stage) + just destruction; lamina dura visible;
cannot see lesion; 10 — 14 days later + lesion + widening of
PDL + visible
• 3. Same for lateral lesions
o Pe riapical cemental dysplasia
• Most often in frontal mandibular periapical region
o 2. Lesionslarger than 1cm diameter + cysts
• 5. Treatment
o 1. Root canal treatment
o 2. Extraction
A: Healthy tooth in X — ray
B: Widening of periodontal ligament, lamina

dura intact + can be caused by overload of
tooth (filling too high or grinding); tooth is
vital; can also be pulpitis (early stage,
reversible)
C: periapical lesion, lamina dura destroyed

by bacteria, pulp is infected or dead +
check vitality oftooth;
D: Acute periapical inflammation (no

smooth borders)
E: Radiopaque, sclerotic bone; PDL is

normal, lamina dura normal, pulp is vital,
condensing osteitis caused by chronic
process in pulp + reaction of apical bone
F: chronic apical periodontitis, periapical

granuloma; can shift to acute again
Periapical abcess ~ Oste omyelitis

Caries~ a c.te ~
Necrotic pulp ~ a p ical periodontitis
Traum~ chronic
Periapical granuloma ~ Pe r iapical cyst

24.2. Osteom elitis

o 1. I nflammation of bone + s p r ead through bone (marrow, cortex,
periosteum)
o 2. Bacteria from abscessed teeth/post — surgical infection which reach
bone marrow
o 1. Acute phasecan affect all ages
• 1. Rapid onset+ pain
• 2. Swelling adjacent soft tissues, fever, lymphadenopathy
• 3. Associated teeth + mobile/sensitive to percussion
o 2. Chronic phase + less severe symptoms
o 1. Location
• Acute + Posterior parts of mandibula
• Chronic + Posterior parts of mandibula
o 2. Periphery
• Acute + Most often ill defined; gradually turns into normal
bone pattern
• Chronic + Ilost often ill defined; gradually turns into normal
bone pattern; Sequestra (re — attached, necrotic bone; needs
surgery + antibiotics!)
• Acute + Slight decrease in density and loss of/changes in
trabecular pattern
• Chronic + changes in trabecular pattern + 'moth eaten';
radiolucent/radiopaque; uneven radiopacity
o 4. Effects
• Acute + Periosteal reaction, resorption of bone
• Chronic + altered shape of mandible
o 1. Fibrous dysplasia
o 2. Paget's disease
o 3. Osteosarcoma
• 5. Treatment
o 1. Acute
• Removal of so u r ce of in f l ammation, antibiotic treatment,
drainage
o 2. Chronic
• 1. More difficult to treat than acute
• 2. Surgical removal of inflammation
• 3. Anti — inflammatory agents (NSAIDs)
• 4. Anti — biotics
Infection perforates bone

and damages it; periosteum
produces new bone
(healing) + periosteal
reaction
Causes + d47 or d48

S
)
2 5. Dental anomalies: su e rnumera tee t h d e n s

inva inatus u l st o n es. Definition clinical features
radio ra hie features differential dia nosis
2 5.1. Su ernumera t e e th
• 1. Definition
o 1. Teeththat develop additionally to normal dentition + result of excess
dental lamina in jaws
o 2. Mesiodens(btw. Maxillary central incisors), Peridens (premolar area),
Distodens (molar area)
o 1. Prevalence 1 — 4%
o 2. Male:Female + 2:1
o 3. More commonin permanent dentition
o 4. May interferewith normal tooth eruption
• 3. Radiographic features
o 1. Variable; may appear entirely normalbut may be smaller in size
o 2. Easily identifiedby counting all teeth in jaws
o 3. Occlusal radiographs may aid determining location
o Mu ltiple supernumerary teeth + associated with number of genetically
inherited syndromes (cleidocranial dysplasia, Gardner's syndrome)
25.2. Dens inva inatus

1. Definition/development
o 1. Consistsof 3 entities + all result from varying degrees of invagination
or infolding of enamel organ into interior of tooth
o 2. Invaginationcan occur in cingulum area (dens invaginatus) or incisal
edge (dense in dente) or in root; may involve root canal system
o 3. Coronal type linedwith enamel; radicular type with cementum
2. Clinical features
o 1. M ay appear as small pit between cingulum + lingual surface of
incisor
o 2. Most oftenin permanent maxillary lateral incisors (followed by central
maxillary); less often in molars
o 3. Invagination + rarein mandibular+ milk teeth
o 4. Clinical importance + riskof pulpal inflammation
3. Radiologic features
o 1. Can be identified even before tooth erupts
o 2. I nfolding of enamel lining + m o re radiopaque than surrounding
tooth structure + ' i n verted tear drop shaped radiolucencywith
radiopaque border
4. Differential diagnosis
o On ce identified, almost impossibleto confuse with other pathology
25.3. Pul stones

1. Definition/development
o 1. Areas of calcificationin dental pulp + most are microscopic; vary in
size
o 2. Some almost fill whole pulp chamber(only these are radiographically
visible)
o 3. Etiology unclear
2. Clinical features
o Not clinically visible
3. Radiologic features
o 1. Variable
• 1. No uniform shape exists
• 2. Radiopaque structures within pulp chamber or extent from
pulp chamber into root canals
• 3. Several small radiopacities/single big mass
4. Differential diagnosis
o 1. Recognitionusually not difficult
o 2. Pulp sclerosis(sometimes)
26: Odonto enic keratoc stic tumor KOT . Definition

clinical features r a dio ra hi c f e atures d i fferential
dia nosis.
o 1. KOT + rare & benignbut locally aggressive developmental cyst
o 2. D ifferent growth mechanism + n o r mally cysts grow by osmotic
pressure; keratinized + t hin lining epithelium of K OT + gro w t h
potential like benign tumor
o 3. Developfrom odontogenic epithelium in alveolus (leftovers from tooth
development)
o 1. Usually asymptomatic;may have mild swelling
o 2. Painin secondary infection
o 3. High chanceof recurrence
o 1. Location
• Posterior portion of mandible; can have pericoronal position of
impacted tooth
o 2. Periphery
• Well defined borders, corticated borders, circular, scalloped
outline
• Radiolucency, curved internal septa + can giveappearance of
multi — locular lesion
o 4. Effects
• 1. Can give rise to satellite cysts
• 2. Minimal expansion of bone
o 1. Dentigerous cyst
o 2. Simple bone cyst
o 3. Ameloblastoma
5i
it
D38 extracted; something coming out from wound

KOT + resorption of root and displacement of
d38; almostno expansion of mandibula (clinically) + x — ray lesion does not expand mandibula
27: Torus a l a tinus T orus mandibularis. Definition

clinical features r a dio ra hi c f e atures d i fferential
dia nosis treatment.
27.1. Torus alatinus
o Hy perplasia; bony protrusion/exostosison palate
o 1. Ilostare less than 2cm in diameter; can change throughout life
• Size varies
o 2 . -20% prevalence; Female/Male + 2:1
• 1. Location
• In periapical or panoramic + r a d i opaque shadows in
midline of hard palate/over apical area of maxillary teeth
• 2. Periphery+ Shape
• Well — defined, smooth — roundish borders
• 3. Internal structure
• Homogenously radiopaque
o 1. Squamous cell carcinoma
• Not as hard; mucous membranes usually ulcerated
o 2. Adenoid cystic carcinoma
• Rare tumor + can start in minor salivary gland over hard palate;
this tumor will not be in midline!
• 5. Treatment
o 1. Usually no treatment required
o 2. If removal necessary(due to maxillary denture) + surgical removal
Torus
The doctor uses drills, osteotomes,

Excision of torus or files to remove and contour the bone
27.2. Torus mandibularis

o Hyperostosis + p r o trudes from lingual aspect of mandibular alveolar
process; usually near premolar teeth
o 1. 90% bilateral (both sides of mandible)
o 2. Size varies
• Small outgrowth or one that contacts other side's torus
o 3. 8% in population
o 4. Develops later than palatinus; mid — life
• 1. Location
• Lingual side of mandibula; premolar region
• 2. Periphery+ Shape
• Well — defined, s m ooth — r o u ndish b o r ders, d e nse
radiopaque shadows
• 3. Internal structure
• Homogenously radiopaque
o 1. Abscess formation
o 2. Bone cancer
o 3. Salivary gland/vascular tumors
o 4. Fibromas
• 5. Treatment
o 1. Usually no treatment necessary
o 2. Surgical removal if:
• 1. Ulcers could from in area of tori due to trauma
• 2. When dentures are required
• 3. May reform!
28: Osteoma. D efinition c l i n i cal f e atures r a d i o r a h i c f e a t ures

differential dia nosis treatment.
o B enign tumor + new piece of bone usually growing on another piece
of bone
o 2. Can form from membranous bones of skull + face
• Neoplasm of nose+ paranasalsinuses
o O nly symptom + asymmetry caused by bony, hard swelling on jaw
o 1. Location
• 1. Mandibula > maxilla
• 2. Mandibular ramus, condylar process, head, frontal sinus
o 2. Periphery + Shape
• Well defined
• Radiopaque
o 4. Effects on surrounding structures
• Can cause dysfunction
o 1. Hyperplasia
o 2. Osteochondroma
o 3. Condylar hyperplasia
o 4. Osteophytes
• 5. Treatment
o 1 . Ma y n o t r e q u ire t r eatment + if i t d o e s n o t i n t e rfere n o rmal
function/cosmetic issues
• Kept under observation
• 2. Surgical removal
29: Od o n toma. Def i n ition cli n i ca l fea t u res

radio ra hicfeatures differential dia nosis treatment.
o 1. Nlost common odontogenic tumor
o 2. Nlixed tumor + odontogenic epithelium+ ectomesenchyme
o 3. Histologically characterized by production of mature enamel + dentin
+ cementum + pulp tissue
o 4. 2 types + complex & compound
0 1. Limited + slow growth
o 2. Well differentiated tooth tissue
o 3. Interference with eruption of permanent teeth; develops when normal
dentition is forming + frequently associated with unerupted tooth
o 1. Location
• 1. Compound + anterior maxilla
• 2. Complex + Mandibular molar region
• 1. Well — defined, corticated border; may be smooth or irregular
• 2. Adjacent to cortical border + soft tissue capsule (radiolucent
band inside cortical border)!
• Depending on type + s mall teeth or dental tissue mixture +
radiopaque
• 1. 70% associated with unerupted tooth
• 2. May expand mandibular bone (if large)
o 1. Cemento — ossifying fibroma
• Odontoma differs by its tendency to associate with unerupted
molar teeth+ odontoma usually more radiopaque
o 2. Periapical cemental dysplasia
• Multiple lesions; centered periapical region of teeth
• 5. Treatment
o 1. If left untreated + persist; but no increase in size
o 2. Usually simply excision + no recurrence
Radiopaque mass with radiolucent band

Radiopaque mass (small teeth) with radiolucent capsula band
around; d48 has been retained
Huge radiopaque mass; d45 and d46 are retained

30. Ameloblastoma. Definition clinical features

radio ra hic features differential dia nosis
treatment.
o 1. Odontogenic epithelial tumor
o 2. Aggressive but benign neoplasm + arisesfrom remnants of dental
lamina + dental organ
o 3. Nlay formfrom epithelial lining of follicular cyst
o 4. Nlalignant forms exist
o 1. Grows slowly; 1%of all oral tumors (18% of odontogenic tumors)
o 2. Few symptoms
• 1. Patient eventually notices facial asymmetry
• 2. Swelling of cheek, gingiva or hard palate
• 3. No pain
o 1. Location
• 1. Mandibula (80% cases) > Nlaxilla
• 2. Ramus, wisdom tooth region
o 2. Periphery+ Shape
• Well — defined, curved border
• From total radiolucent to total radiopaque
• Can have bubble appearance
• 1. Root resorption, tooth displacement
• 2. Expansion of bone (severe)
o 1. Dentigerous cyst
o 2. KOT
o 3. Giant cell granuloma
o 4. Nlyxoma
o 5. CT/MRTis highly recommended!
• 5. Treatment
o 1. Surgical removal
• 1. Ameloblastoma tend to in vade adjacent bone beyond its
radiographic margins + intra — oral approach in case of small
lesion; resection of jaw might be needed if large lesion
• 2. Radiation therapy for in —operable tumors (posterior maxilla)
• 3. May recur if initial surgery does not remove entire tumor +
recurrent lesion more aggressive than original one
i•
I
• • •
e
31: S uamous cell carcinoma. Definition clinical

features radio ra hie features differential dia nosis
treatment.
o 1. Most common oral malignancy (90%); men > 50yrs
o 2. Originatesfrom surface epithelium (malignant tumor)
o 3. Invasionof malignant epithelial cells into underlying CT + spread
into deeper soft tissues + adjacent bone/local lymph nodes and then to
different sites such as lungs/liver/skeleton
o 4. Uncommon;may arise from soft tissue, bone, cysts, ameloblastoma,
maxillary sinus
o 1. Startsas white, red or mixed irregular patchy lesion (on epithelium)
o 2. Ulcerationover time
o 3. Palpable infiltrationinto adjacent muscle/bone
o 4. Paresthesia, Anesthesia, Dysesthesia
o 5. Foul smell, loosened teeth, trismus, hemorrhage, weight loss
• 1. Irregular, ill — defined borders
• 2. Finger — like projections
• Demonstrating invasion in surrounding bone
• 3. Sometimes + smooth borders
• Indicating erosion (surface of bone)
• 4. Pathologic fractures may occur
• Due to sharp, thin edges of bone fragments
• 5. Destruction of anatomical structures
• 1. SCC + completely radiolucent
• 2. There may be trapped pieces of bone inside lesion
o 3. Effects on surrounding tissues
• 1. PDL initially appears widened + destruction of Lamina Dura +
teeth will appear to 'float' in lesion + may be displaced as lesion
expands
• 2. Tumor may spread in mandibular canal
• Widened appearance of canal; clinical signs appear for
patient
• 3. Adjacent cortical borders may be destroyed
o 1. Clinical + histological features!
• Advanced imaging + biopsy
o 2. Osteomyelitis
o 3. Osteoradionecrosis
• 5. Treatment
0 1. Lethal if left untreated
o 2. Co m b ination of sur g ery + rad i a tion t h e rapy; c o n comitant
chemotherapy
Right side; SCC with relatively smooth

borders, soft tissue mass on top
Mandibular canal disappears where

tumor is located
• 1f
Destruction of bone; no bone support

on d47; no smooth borders; radix
almost floating in air with no support
(1) Left side molar region + no

smooth borders
r
Apical part of d36 almost free; soft
tissue mass on top of lesion
'•
(2) Same patient; 6 months later
Lesion has grown very fast;

pathological fracture is visible on
left side + bone very thin/fragile
(3) Final X — ray
Fracture has not healed; tumor grew

even bigger
4th quadrant; destruction of

alveolar process+ soft tissue
mass
Patient complains for few

months about pain
SCC in 4'" quadrant
SCC (4'" quadrant); from

premolar region with
relatively smooth borders
Soft tissue mass on top of it

32. Osteosarcoma. Definition clinical features

treatment.
• 1. Definition
o Ag gressive malignant neoplasmof bone in which osteoid is produced
directly by malignant stroma
o 1. Rare; jaws account onlyfor 7% of all osteosarcomas
o 2. Male/female + 2:1
o 3. Peakin 4'" decade
o 4. I nitially reported by swelling/bleeding; other + p a i n, ulceration,
loose teeth
o 1. Location
• 1. Nlandibula (more common)
• Posterior part + molar+ ramus area
• 2. Nlaxilla + posterior
• Ridge, sinus, palate most commonly affected
• 1. ill — defined
• 2. Radiolucent
• Without capsule/surrounding osteosclerosis
• 3. If periosteum involved + sunray spicules may be present
• 1. May be radiolucent, mixed, completely radiopaque
• 2. Varied osseous appearances
• G r anular, cotton wool, wisps
o In all cases + trabeculationis lost
o 1. Fibrosarcoma or metastatic carcinoma(if osseous structure is visible
+ consider osteosarcoma)
o 2. Physical examination+ laboratory tests
• 5. Treatment
o 1. Resectionwith larger border of adjacent, normal bone
o 2. Complicated + important adjacent anatomic structuresof head +
neck
o 3. Radiation + chemotherapyto control metastasis
Sunray appearance; no
normal appearance of
bone; widening of PDL
Radiopacityinstead of
radiolucency
d48 region + cortical border of

d48
Around d47; loss of normal bone

appearance; rugged + uneven
resorption of distal root of d47
Sunray appearance of tumor

33. Soft tissue calcification — calcified I m h nodes

ossification of the st loh oid li ament. Definition
clinical features radio ra hic features differential
dia nosis treatment.
33.1. Calcified I m h nodes
• 1. Definition
o Oc curs in lymph nodes with chronical inflammation (due to various
diseases) + ly m phoid tissue becomes replacedby hydroxyapatite
calcium salts nearly affecting all of nodal architecture
• Presence of calcifications in lymph nodes implies disease (active
or previously treated pathosis)
o 1. Asymptomatic + discovered incidentallyon OPGs
o 2. Il ostcommonly involved nodes:
• Submandibular + deep/superficial cervical nodes
o 3. Leastcommonly involved nodes:
• Pre — auricular + submental nodes
o 4. Palpationof nodes + hard
o 1. Location
• 1. Submandibular region; at/below inferior mandibular border
near angle or between posterior border of ramus+ cervical spine
o 2. Periphery
• Well — defined + irregular borders; lobulated appearance
• 2. Irregularity of shape + significant in differential diagnosis!
• 1. Varies in degree of radiopacity
• 2. May have laminated appearance + r adiopacity may appear
only on surface of node (egg shell calcification)
o 1. Differentiationof single calcified lymph node and sialolith in hilar
region of submandibular gland + difficult because of location
• Sialoliths + smooth outline; CLN + irregular
o 2. Phleboliths + similarin appearance; however smaller multiple with
concentric radiopaque/lucent rings
• 5. Treatment
o 1. Usually none required + underlying causefound and treatment of
that
33.2. Ossification of st loh oid li ament

• 1. Definition
o Os sification of SL usually extends downward from base of skull +
commonly occurs bilaterally; rarely it begins at lesser horn of hyoid
o 1. Detectedby palpation over tonsil + hard, pointed structure
o 2. R arely symptomatic; no correlation btw. extent of ossification +
symptoms
o 3. Associatedwith eagle syndrome + carotid artery syndrome
o 1. Location
• 1. Detected incidentally on OPGs
• 2. Linear ossification extends forward from region of mastoid
process + crosses posterior inferior aspect of ramus toward
hyoid bone
• 1. Styloid process + long, tapering, thing radiopaque structure
(thicker at base)
• 2. Ossified ligament + r o u ghly straight outline; irregular +
radiopaque
• 1. Small ossifications + radiopaque
• 2. If ossification extends length + width + o uter cortex more
radiopaque band (outer part)
o Almost none; maybe TMJ dysfunction
• 5. Treatment
o As ymptomatic + n on e r e q u ired; otherwise amputation(i ntense
symptoms) or lidocaine + steroid injections into tonsillar fossa
34. Traumatic in uries of teeth: concussion luxation

avulsion fractures. Definition clinical features
treatment.
34.1. Concussion Erschutterun
• 1. Definition
o Il i ld trauma; crush injury to vascular structures at tooth apex+ PDL +
inflammatory edema
o 1. Painful to percussion; bleeding around gingiva
o No pathologic changes seen!
• If there is concussion with sensitive tooth + m ake X — ray +
later you may need it after 6 months I 1 year to compare how
tooth feels or changes in tooth (resorptions, pulp necrosis etc.) for
CONIPARISON!
• 4. Treatment
o No special treatment; soft diet 2 weeks
• 5. Differential diagnosis-
34.2. Luxations
• 1. Subluxation
o 1. Partial traumato periodontal ligament (NOT radiologically) but blood
around gum of tooth; NOT visible radiologically!
o 2. X — rayshould be taken for comparison! (like concussion)
o 3. T r eatment + t o o th r estored to no rmal position after accident;
flexibile splint can be used for 2 weeks
y' PP 'Cs~' p '
,l.
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t 'I
)l
• 2. Extrusive Luxation
o 1. Toothis partially fallen out of socket and partially displaced
o 2. Blood around gumof tooth; tooth will be outside its place
o 3. Radiographshows widened PDL
o 4. T reatment + r e p osition tooth by inserting it into socket, flexible
splint (2 weeks); if pulp necrosis + RCT
j
pr
r >T% y
g . AT
'T •
• •
• 3. Intrusive Luxation
o 1. Quite common for residual teeth in children
o 2. Dueto trauma + tooth pushed into bone
o 3. Shortened tooth visible
o 4. PDL not visiblebecause tooth pushes it upward
o 5. T reatment + al l ow eruption w/o intervention if intruded less than
3mm; if no movem e n t afte r 4 weeks + re p osition
surgically/orthodontically before ankylosis develops; if intruded more
than 7mm + immediate surgical reposition; flexible splint 4 — 8 weeks
r(
A'
• 4. Lateral Luxation
o 1. Rootof tooth in incorrect position (lateral, anterior, posterior direction)
o 2. Combineswith alveolar process fracture (usually)
o 3. X — ray + like Extrusion
o 4. Treatment + reposition toothinto original place (fingers or forceps) +
flexible splint 4 weeks; pulp necrosis + RCT
~ ~ . )~i
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T •
r
34.3. Avulsion
• 1. Tooth fallen out completely due to trauma; socket is empty
o Mo st commonly max. central incisor; fractures alveolar process may
be seen
• 2. Patient eventually brings tooth with him + place back+ put back
• 3. Treatment
o 1. Find avulsed tooth
• Re — implant permanent tooth after avulsion; prognosis depends
on + co n ditionof tooth while outside mouth, time it is out of
socket, viability of residual PDL fibers
o 2. Flexible splint, soft diet, excellent oral hygiene, Antibiotics, CHX
o 3. RCTmay be necessary after replacement
o 4. R e — implanting deciduous tooth + d a n g erous for underlying
developing permanent tooth
34.4. Fractures
• 1. Horizontal root fracture
o 1. Inside bone roothas fractured horizontally
o 2. Clinically difficultto see
o 3. X — ray required
• In every case 2 X — rays + different angles; in 1 projection we
can miss fracture because it can overlap and hide
Straightfracture
'4 ' •
but in real life it can

be on several levels
')
t
Can be oblique; in
that case it will be
round on X — Ray
On different
levels + looks
like thick line
• 2. Vertical root fracture

o 1. Not always connected to accidental trauma
• Can occur from biting something hard
o 2. Clinically, changesin gum + fistula can be seen
o 3. Complaintsof patient with such tooth + no serious complaints; may
notice different feeling in tooth on biting; no real pain; takes months
sometimes before diagnosis + poor prognosis! Extraction!
o 4. On X — ray + lateral radiolucency around root visible
Fracture on d34 (endo);

widened PDL around +
verticalfracture; tooth
afterextraction
Fracture not
seen but
widening of PDL
D36 endo + 1 month later

huge radiolucency; vertical
fracture of distal root!
Fistula with Gutta Percha inside;

tooth d45 radiolucency all around
root + vertical root fracture
35. F ractures o f ma x i ll a z or n a . R a d i olo ical

dia nostics.
35.1. Fractures face e n e rall
• Radiolucent features
o 1. Sharp, radiolucent linewithin anatomic structures
o 2. Deviationfrom normal anatomic line
o 3. Discontinuityin cortical border or step — formation
o 4. Sometimes increased density(of bone)
• 2. Imaging
o 1. Head, chest, abdominal trauma + priority
• Face is not priority! Checked after priorities
o 2. Best way + computer tomography
o 3. Il andibular fracture + panoramic X — ray
• 3. Mid — facial trauma
o 1. Orbital blow out fracture
o 2. Nasal bone fracture
o 3. Zygomatic fracture
o 4. LeFort fractures
35.2. Z o m atic bone fracture

• 1. Tripod structure
o Wh ere zygomatic bone+ adjacent areasof maxillary, sphenoid, frontal
temporal bones may be involved; along sutures
• 2. Arch fracture (arcus zygomaticus)
• 3. LeFort 2+ 3 structure
Zygomatic bone impression

fracture in 3 parts also in
connection to maxillary bone
Tripod fracture of zygomatic bone
35.3. Maxilla f r actures LeFort

• 1. LeFort I
o Re latively horizontal fracture in body of maxilla + d e t a chment of
alveolar process + adjacent bone of maxilla from mid — face
o 2. Fracture plane + superiorto roots of teeth+ nasal floor; posteriorly
through base of maxillary sinus + tuberosity
o 3. Anterior open bite, swelling(above upper lips), bruising around eyes,
pain over nose + face, mobile maxilla
• 2. LeFort II
o 1. Fracture separates maxillafrom base of skull
o 2. F racture plane + extendsfrom bridge of nose inferiorly, laterally,
posteriorly through nasal + lacrimal bones; orbital floor + inferior rim
obliquely + inferiorly across maxilla
o 3. M assive edema in middle third of face; ecchymosis around eyes
within minutes of injury, bloodshot eyes, broken + displaced nose
• 3. LeFort III
o 1. F racture plane + e x t ends from nasal bone + frontal process of
maxilla or naso — frontal + maxillo — frontal sutures, across orbital floor,
through ethmoid air cells + sphenoid sinus to zygomatico — frontal
sutures
o 2. Nlore posteriorly+ inferiorly + fracture planepasses across pterygo
— maxillary fissure and separates bases of pt erygoid plates from
sphenoid bone
Q C3
LeFort II with combination of LeFort I

36. Fractures of mandible. Radiolo ical dia nostics.

• 1. Imaging
o 1. Use plain filmsand panoramic OPG
o 2. Computer tomographyif complicated
• 2. Prevalence of fractures of anatomic parts of mandible
o Al ways check opposite sideof mandible too + due to oval structure
of mandible it can break both sides
sub condyiar
Bod 30 — 40% ~ c oronold
An le 25 — 30% procoss
Cond le 15 — 17% condylar

S m h si s 7 — 15%
Ramus 3 — 9%
Alveolar bone 2 — 4% 7I
Coronoid rocess 1 — 2% body ansto P
sympbysls body
.(" Angle fracture
Both angles fractured +

j will be fixated with metal
I *
Symphysis fracture
Fracture with fragmentation

in parasymphysial region
Distortion/dislocation of
occlusal planes + fixated
with metal
Body+ Processus condylaris fracture
Also fixated with metal

Ramus+ Angle fracture
p -g~h Angle (right); Ramus (left)
Dislocation + fragments are

overlapping; distortion of
occlusal plane
Symphysis + Ramus fracture
Ramus fracture is vertical on left side
[
I
Body+ Processus coronoideus +

Processus condylaris fracture
Right side (body), processus

condylaris + coronoideus (left)
In processus coronoideus fracture +

check upper jaw; not seen here +
make CT!
Processus coronoideus fracture

(right) + lateral wall of maxillary
sinus
37. I m lant radiolo : lann i n ost — o e rative

assessment com lications.
37.1. Pre — o erative lannin
1. X — rays help surgeon to visualize alveolar ridges + adjacent structures in
3D and guide choice of site, number, size and axial orientation of implant
2. Site selection + includes consideration of following structures:
o In cisive + mental foramina, mandibular canal, existing teeth, nasal
fossae, maxillary sinuses
3. Conditions + pathologies that might compromise outcome + identified +
located
o Re tained roots, impacted teeth
4. Diagnostic images of potential implant sites may provide information about
quality + quantity of bone
5. Quality of bone + includes assessment of cortical bone + the thicker the
better chances of osseointegration; higher number of trabeculae also good
6. Bone quantity assessed by height + width of alveolar bone + morphology
of ridge
7. Cross — sectional image document facial + lingual width/height of ridge
along with inclination of bone contours
o Al veolar ridge width helps selecting implant diameter + maximal
placement
8. When measurements made on any image + m a g n ification has to be
considered; magnification factor
37.2. Post — o erative assessment

1. Intraoral —and panoramic radiographs used
2. 2 aspects are usually assessed afterwards
o 1. Alveolar bone heightaround implant
o 2. A p pearance of bo ne i mmediately adjacent to a nd su rrounding
implant
3. Since exact angulation of implant not known + n ot always predictable
procedure
o 1. Angulationof X — ray beam must be within 9' of long axis of fixture to
open thread on image
o 2. Deviationsof 13' or more + overlapping of threads
4. PAs + longitudinal assessments
5. Mesial + distal marginal bone height measured from standard landmark at
collar of implant or interthread measurement + compared with bone levels in
previous PAs
37.3. Com lications Radio ra hic a ea r a nce+ its failure

• 1. Thin radiolucent area that closely follows entire outline of implant
o + fa i lureof implant to integrate with adjoining bone
• 2. Crestal bone loss around coronal portion of implant
o + os t eitis due poor plaque control, adverse loading(or both)
• 3. Apical migration of alveolar bone on one side of implant
o + no n — axial loading resulting from improper angulation of implant
• 4. Widening of PDL space of nearest natural tooth
o + po o r stress distribution resultingfrom biomechanically inadequate
prosthesis — implant system
• 5. Fracture of implant fixture
o + un f avorable stress distribution during function
38. Saliva land radiolo . S i a loliths. Stafne bone

est.
~
38.1. Sialoliths
• 1. Definition
o 1. Stonesfound within ducts of salivary glands
o 2. Mechanical conditions + physiochemical characteristics of gland
secretion contribute to sl ow f low r ate + fo r m a tionof ni dus +
precipitation of calcium+ phosphate salts
o 1. Most commonin submandibular glands of men (35+ yo)
o 2. Usuallyoccur singly (70 — 80%) but may be multiple + especially in
parotid gland
o 3. P atient may be asymptomatic; but usually have history of pain +
swelling in area of involved gland
• Discomfort may intensify at mealtimes
o 4. S tone usually dot not block flow of saliva completely + p a in +
swelling subside
o 5. 9 % pat i e nts ha v e re c u rrent s i a lolithiasis; 1 0% h a v e al s o
nephrolithiasis
• 3. Radiographic features
o 1. Location
• 1. Submandibular gland + 83 — 94%
• 2. Parotid gland + 4 — 10%
sialography — > contrast injected into
• 3. Sublingual gland + 1 — 7% glan d — > x ray (mand occ) or mrt/ct
0 2. Periphery+ Shape
• 1. Sialoliths located in duct of submandibular gland + cylindrical
+ very smooth outlines; in hilus of gl and + l a r g er + mo r e
irregular
• 1. Homogenously radiopaque; some show multiple layers of
calcification
• 2. Less than 20% of submandibular gland Sialoliths and 40% of
those in parotid gland + radiolucent + low mineral content of
parotid secretions
o 1. Can be distinguished from other soft tissue calcifications + usually
associated with pain/swelling of involved area
o 2. Other calcifications(e.g. lymph nodes) + asymptomatic;if diagnosis
unclear + sialogram
• 5. Treatment
o 1. Small stones + 'squeezed out' through duct orificemy bi — manual
palpation
o 2. I f s t one too large/located in proximal duct + n o n — surgical /
minimally invasive sialolithotomy
o 3. Very large stones + surgical removalof stone/gland
38.2. Stafne bone c sts/Cavities

o 1. Developmental disturbance
o 2. Mostlyseen in areas where major salivary glands are localized
closed to bone surface (submandibular gland, sublingual gland)
o 3. Press finger + impression + extensive growthof gland; no
treatment needed; usually below mandibular canal + radiolucent dot
Looks like radicular cyst; 3D

image shows where sublingual
gland is situated
J g
I
I
r
r
1. maxillary sinus 25. sigmoid notch

2. pterygomaxillary fissure 26. medial sigmoid depression
3. pterygoid plates 27. styloid process
4. hamulus 28. cervical vertebrae
5. zygomatic arch 29. external oblique ridge
6. articular eminence 30. mandibular canal
7. zygomaticotemporalsuture 31. mandibular foramen
8. zygomatic process 32. lingula
9. external auditory meatus 33. mental foramen
10. mastoid process 34. submandibular gland fossa
11. middle cranial fossa 35. internal oblique ridge
12. lateral border of the orbit 36. mentalfossa
13. infraorbital ridge 37. mental ridges
14. infraorbital foramen 38. genial tubercles
15. infraorbital canal 39. hyoid bone
16. nasal fossa 40. tongue
17. nasal septum 41. soft palate
18. anterior nasal spine 42. uvula
19. inferior concha 43. posterior pharyngeal wall
20. incisive foramen 44. ear lobe
21. hard palate 45. glossopharyngeal air space
22. maxillary tuberosity 46. nasopharyngeal air space
23. condyle 47. palatoglossal air space
24. coronoid process

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a io o

2. Paralellin t e c hni u e b a si c ri n c i le s oss i b le

o Co tton rollsused in places of missing teeth I

• 4. If holders with ring used + ring as close to face as possible

2.3. Possible mistakes

3.3. Indications 8 Inter retation

4. Peria ical X — ra s indications.

5.2. Occlusal techni ue LOWER aw

6. Processin ste s of an X — ra film

7. Infection control in dental radiolo

7.2. Universal recautions

7.3. Ste s of infection control

8. Paranasal sinuses radiolo ical methods dia nostic

8 .2. Dia nostic informativit i n intraoral and a n o ramic radio ra h s

9 . Dia nostic i m a i n of t e r n o r o m andibular o i n t

Lateral pterygoid muscle

9 .2. Dia nostic informativit /main disease affectin T M J + th e i r

10. Panoramic r a diolo indications d i a n o stic

10.3. Advanta es 8 Disadvanta es dia nostic informativit

11. Panoramic radiolo - ositionin m i s takes

Too far backwards + too far away from film +

Patient rotated to the LEFT +

LEFT molars CLOSER to film + SMALLER

RIGHT molars further away from film + LARGER

o 2. Head+ chin raised upwards, Frankfort plane not horizontal +

12. Radiolo ical si ns ofbeni n tumors in aws.

13. Radiolo ical si ns of mali nant tumors in aws.

o 4. Cortical bone destruction appearances

1 4. SLOB rule an d s e a r ation o f r o o t c a nals i n

14.2. SLOB rule / Parallax/ Ob ect localization

15. Normal radio ra hic anatomic structures in anterior

FIG. 10-9 The alveolar crests(arrows) are seen as cortical borders of

15.2. Anatomic structures in anterior maxilla

FIG. 10-aa A, The incisive foramen appean as an ovoid

FIC. 10-26 The lateral fossa is a diffuse radiolucency (onows) in the

FIG. 10-28 The nasolacrimal canal (anow) is occasionally seen near

1 6. Normal r a dio ra hi c a n a tomic s t ructures i n

Fl( . 10-30 T he inferior border of the maxillary sinus(arrotrirs)appears

lo tas»mq»eamo n~ srlT ae® I' .QIR

17. Normal radio ra hic anatomic structures in anterior

FIG. 10%$ Mental ridge (arrows) on the anterior surface of the

FIG. 10-40 The mental fossa is a radiolucent depression on the ante-

1 8. Normal r a dio ra hi c a n a tomic s t ructures i n

FIG. 10-59 The inferior border of the mandible(arrows) is seen as a

19: Radicular and residual c sts. Definition clinical

Cyst from d46 (deep

20: Denti erous f ollicular c s ts. Definition clinical

Dentigerous cyst + d38 is retained; cystic lesion

21: Lateral er i o dontal c s ts . D e f inition c l i nical

22. Sim le bone c s ts. Definition clinical features

23: Naso alatine d uc t c s t s . D e f inition c l i nical

24. Inflammation in aws: e ria ical inflammato

A: Healthy tooth in X — ray

B: Widening of periodontal ligament, lamina

C: periapical lesion, lamina dura destroyed

D: Acute periapical inflammation (no

E: Radiopaque, sclerotic bone; PDL is

F: chronic apical periodontitis, periapical

Periapical abcess ~ Oste omyelitis

Periapical granuloma ~ Pe r iapical cyst

24.2. Osteom elitis

Infection perforates bone

Causes + d47 or d48

2 5. Dental anomalies: su e rnumera tee t h d e n s