Imaging, 22 (2013), 20110002

HEAD AND NECK IMAGING

Dentomaxillofacial imaging and interpretation

J E BROWN, FDSRCPS, DDRRCR and B L THOMAS, BDS, PhD

Kings College London, Unit of Dental and Maxillofacial Radiological Imaging, Guys and St Thomas
NHS Foundation Trust, London, UK

Summary
Dental radiography is widely practised and accounts for 26% of all medical
exposures in the UK.
Imaging of a variety of lesions found characteristically in the dental and
maxillofacial region is reviewed through the medium of these common
radiographic examinations.
Interpretation in the maxillofacial region is helped by an understanding of dental
notation and the development of the dentition, and related dental developmental
anomalies are described. doi: 10.1259/imaging.
Prevalent dental conditions such as caries and periodontal disease are explained 20110002
and radiological features illustrated.
A strategy for interpretation in the dental and maxillofacial region is introduced. 2013 The British Institute of
Radiology

Cite this article as: Brown JE, Thomas BL. Dentomaxillofacial imaging and interpretation. Imaging 2013;22:
20110002.

Abstract. This article introduces radiographic imaging and
interpretation in the dental and maxillofacial region. The range
of common intra-oral and extra-oral radiographs is illustrated.
Dental annotation is central to the clear communication of
abnormalities involving the teeth, and the most common
conventions are described. An overview of tooth development is
given in order to understand developmental abnormalities
which include variations in shape and number of teeth, and
syndromes which affect the dentition. Caries and periodontal
disease are the most common disorders affecting the teeth, and
the pathology and radiological features are explained as these
represent the origin for many inflammatory conditions
affecting the jaws. General principles of radiological interpre-
tation within the jaws are described and illustrated with
examples of lesions found within the dental and maxillofacial
regions. Features such as the influence of the site of the lesion,
and considerations of the size and dimensional relationships of
a lesion are discussed. The interpretive features of the outline,
shape and internal character of a radiological abnormality
within the jaws are described. The significance of effects on
adjacent structures is also examined. These principles are
illustrated with examples of infective and inflammatory lesions,
odontogenic cysts and tumours, non-odontogenic cysts and
tumours, multicystic and fibro-osseous bone lesions and
idiopathic phenomena.
Address correspondence to: Dr Jackie Brown, Department of Dental
Radiology, Floor 23, Tower Wing, Guys Hospital, London SE1 9RT,
UK. E-mail: jackie.brown@kcl.ac.uk
The predominant characteristic of dental imaging is the
emphasis on hard tissue depiction using high-definition
and good-contrast images. This is provided by intra-oral
periapical and occlusal radiographs, employing direct
exposure film with a resolution of 1520 line pairs (lp) per
millimetre (Figures 1 and 2). Imaging of the jaws, e.g.
panoramic radiography, uses indirect action film with in-
tensifying screens giving a resolution of around 7 lp mm21.
Films are mounted as if viewing the patient in an ante-
roposterior (AP) direction. Orthodontic and orthognathic
assessment specifically employs lateral cephalometric
views, these being fixed true lateral projections of the
facial bones, with a long (1.52 m) focus-to-skin distance
for minimal magnification.
Traditional film is steadily being replaced by digital
radiography using direct digital radiography (DR) and
computed radiography (CR) in dentistry, with resolving
powers very similar to plain film, but with the advan-
tages of image manipulation, and is now used in ap-
proximately half the dental practices in the UK. More
recently three-dimensional imaging in the form of cone
beam CT (CBCT) has found a role in imaging the teeth
and jaws. Although CBCT is not suitable for pathology
involving soft tissues, it does provide very good reso-
lution, demonstrating fine detail of the hard structures
of the jaws and teeth at much lower doses than for con-
ventional CT.
Intra-oral radiographs are the gold standard in iden-
tifying caries and periodontal disease, with significantly
higher sensitivity and specificity in detection than the

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(a) (b)
(c)
Figure 1. Intra-oral radiographs. (a) Intra-oral long cone
periapical radiograph showing caries in lower right (LR) 5 and
LR7 and apical radiolucencies associated with the mesial and
distal apices of the restored LR6. (b) A left bitewing radiograph.
The levels of the alveolar crest are clearly seen [arrow between
upper left (UL) 4 and 5]. An overhang of the restoration at
distal of lower left (LL) 6 can be seen and a calculus deposit on
the distal surface of LL5 (white arrowhead). (c) An upper
standard occlusal showing a mixed dentition with the upper
right (UR) 1 delayed in eruption due to the presence of an
inverted mesiodens (marked by a star).
dental pantomogram (DPT), where the compound nature
of the image with ghost shadows and loss of detail of
structures outside the focal trough can lead to false-
positive and false-negative detection of these common
diseases. The DPT is useful in providing a general over-
view of the dentition, showing generalised levels of al-
veolar bone, providing information regarding unerupted
teeth, and enabling a wider view of pathology such as
cysts of the jaws with a relatively low dose and is per-
formed very easily in a general dental practice setting. In
common with all areas of radiography, interpretation of
these commonly undertaken radiographs requires an
initial assessment of normal anatomy, identification of
artefacts and then pathological anomalies reported.
Dental annotation
A full dentition comprises 20 deciduous teeth (2 inci-
sors, 1 canine, 2 molars per quadrant) and 32 adult teeth
(2 incisors, 1 canine, 2 premolars, 3 molars per quadrant).
The deciduous dentition is replaced by the permanent
dentition in a gradual sequence extending from around
the age of 6 years to early adulthood as the third molars
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J E Brown and B L Thomas
erupt (Figure 2). The numbers of teeth present in the
jaws (erupted as well as developing) therefore varies
over a significant period, from the initiation of tooth de-
velopment in the 7-week-old embryo, until the eruption
of the permanent third molars late in the second or early
in the third decade [1]. Systems have been developed to
annotate each tooth within the dentition, being important
to allow adequate reporting of missing, misplaced and
malformed teeth. Two main systems are recognised
internationally, the Palmer (Zsigmondy) notation and
the FDI World Dental Federation notation (Figure 3),
and a third, the American Dental Association Universal/
National tooth notation system, has been adopted in the
USA.
Tooth development and anatomy
Each tooth forms with a specific crown and root mor-
phology as necessitated for its function. During tooth
development, a series of intricate reciprocal interactions
between epithelial cells that have invaginated from the
surface of the first branchial arch and migrated neural
crest cells direct the cytodifferentiation required to gen-
erate the highly specialised epithelial ameloblasts that
produce the outer enamel layer of the crowns, and the
highly specialised mesenchymal odontoblasts that pro-
duce the dentine [2]. Many signalling pathways have
now been shown to be involved in both the cytodiffer-
entiation stages in each individual forming tooth and the
complex patterning of each individual tooth shape in the
correct position within the jaws to provide a comple-
mentary upper and lower set of teeth and thus a func-
tioning dentition [3, 4].
There is an extensive period, from the seventh week
of embryogenesis until late in the second decade, when
teeth at different stages of development are present
within the jaws. The earliest radiological evidence of
a toothgerm is the narrow radiopaque enamel/dentine
interface; prior to this, the crypt containing the toothgerm
is seen as a well-circumscribed cyst-like radiolucency
within the jaw (Figure 2a). Calcification of the deciduous
dentition begins with the incisor teeth at 3 months in
utero, and continues until completion of root formation of
the molars at approximately 3 years of age. Tooth for-
mation and eruption proceed sequentially from anterior
to posterior, with toothgerms at various stages of de-
velopment present in each jaw. The lower incisors are the
first to erupt at approximately 6 months of age, whereas
the molars are just completing crown formation at that
stage. This sequential development is mirrored in the
permanent dentition, with the exception of the first molars,
being the first permanent teeth to form and erupting
around 6 years of age. This is followed by eruption of the
incisors and again an anterior to posterior sequence of
development and eruption, with the second molar teeth
erupting around 1213 years. The final teeth to form are
the third permanent molars (wisdom teeth), where
eruption can occur in the late second or third decade.
This extended sequence of formation of the dentition
produces a complicated image on a DPT. However, it can
provide a good indication of a patients age, and can help
to identify missing and unerupted teeth.
Given the extensive invagination of epithelium into
the mesenchyme and encapsulation in the bony jaws, it
Imaging 2013, 22, 20110002
Dentomaxillofacial imaging and interpretation
(a)
(b) (c)
Figure 3. Tooth annotation. (a) The FDI system of tooth
identification allocates a two-digit number to each tooth.
The first digit refers to the tooth quadrant (permanent
dentition: upper right (UR) 5 1, upper left (UL) 5 2, lower left
(LL) 5 3, lower right (LR) 5 4; deciduous dentition: UR 5 5,
UL 5 6, LL 5 7, LR 5 8). The second digit refers to the tooth,
counting out from the central incisor as 1 to the third molar
as 8. (b) The Palmer (Zsigmondy) system of tooth annotation
numbers permanent teeth from 1 to 8 starting from the
central incisor to the third molar in each quadrant, and for
the deciduous teeth from A to E from central incisor to
second molar. The quadrant is indicated by a quartered clock
face of lines; _/ 5 UR, /_ 5 UL, / 5 LR and / 5 LL. UR right
central incisor could therefore be written as either 1 or UR1.
imaging.birjournals.org
Figure 2. Dental panoramic tomogram
(DPT) (a), and right (b) and left (c)
bitewings of a child aged approxi-
mately 89 years in age in the mixed
dentition, demonstrating the unerup-
ted canines, premolars and second
molars in all quadrants and follicles of
the third molars where the first signs of
mineralisation are visible [arrow show-
ing lower right (LR) 8 socket]. All
deciduous canines and molars are
retained; there is extensive caries in
the posterior teeth; note caries in URD,
LRD and LLD are clearly demonstrated
in the bitewing views but less clear to
see on the DPT.
is hardly surprising that remnants of these embryonic
cells can remain in situ, acting as nidi for formation
of cysts and tumours of odontogenic origin in later life.
Three groups are known to be involved in forming
cysts of the jaws: first the epithelium that invaginated
at the start of tooth formation can leave residual cells,
known as the rest cells of Serres; second, the reduced
enamel epithelium lining the tooth follicle surrounding
the crown at the completion of enamel formation giv-
ing rise to dentigerous cysts; third, Hertwigs root
sheath, the epithelial cells that grow down from the
periphery of the crown during root formation can leave
residual cells known as the rest cells of Malassez.
Developmental anomalies of teeth
Developmental abnormalities affecting the dentition
include variations in the number, size and shape of the
teeth and abnormalities in formation of the mineralised
tissues.
An abnormal number of teeth can be a result of missing
or extra teeth. Congenitally absent teeth almost invariably
affect the permanent dentition rather than the deciduous
dentition, most frequently involving the third molars, fol-
lowed by the second premolars and maxillary lateral
incisors. More extensive absence of teeth may be seen;
oligodontia is the absence of numerous teeth and anodontia
is the complete absence of teeth. Multiple missing teeth are
frequently seen in syndromes such as ectodermal dysplasia,
but may also be seen in otherwise healthy patients, often
as a familial trait [57]. Other causes of missing teeth in-
clude trauma, infection, radiation and chemotherapy.
Additional, supernumerary teeth may occur anywhere in
the tooth-bearing areas of the jaws. Such teeth rarely erupt,
and are more likely to be incidental radiographic findings
or identified during investigation into failed eruption of
3 of 12

(a)
(b)
Figure 4. Reconstructed panoramic (a) and cone beam CT
MIP projection image (b) of the jaws in a child of 8 years with
cleidocranial dysplasia syndrome, showing multiple unerup-
ted supernumerary teeth.
a permanent tooth. A common position to find a single
supernumerary is between the maxillary central incisors
(Figure 1c), and for multiple supernumerary teeth is in the
mandibular premolar regions. Multiple supernumerary
teeth are found as part of cleidocranial dysplasia syndrome
(Figure 4); here numerous supplemental teeth (teeth of
correct morphology for the region of the jaw) form, but
overcrowding and impaction necessitates surgical re-
moval. Difficulties can arise in deciding which teeth
should be saved, depending on their morphology and the
surgical accessibility to remove less favourable teeth;
CBCT is proving to be a very valuable tool in such cases,
but careful annotation is required to adequately report
the true permanent teeth and the supernumeraries.
Variations in tooth size including both macrodontia
(enlarged teeth) and microdontia (small teeth) can affect
the whole dentition, a few teeth or a single tooth. The
most common presentation of microdontia is diminutive
peg-shaped maxillary lateral incisors.
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J E Brown and B L Thomas
Root dilaceration may affect the permanent maxillary
incisors following intrusion injury of the overlying de-
ciduous incisor. Such trauma may displace the crown of
the developing permanent incisor, resulting in angulation
of the crown relative to the root, which may prevent its
eruption. Small dilacerations, with hooks in the apical
third of roots, are very common and can impede extrac-
tion of a tooth, particularly the lower third molars.
Defects early in toothgerm formation can lead to var-
iations in tooth shape. The first part of the tooth to form
and mineralise is the incisal edge or cusp. Excessive cell
division and/or reduced apoptosis can lead to an out-
growth (dens evaginatus) or ingrowth (dens invaginatus)
as a cusp forms, with a resultant extra, small cusp or an
excessively deep pit, the clinical significance being that the
pulp chamber is readily breached, in both cases leading to
pulp necrosis and sepsis; there is therefore a radiological
need to identify such abnormalities. Less frequently seen
abnormalities of tooth shape are fusion or concrescence
of two adjacent teeth, gemination (partial division) of a
tooth, and taurodontism (longitudinally enlarged pulp
chambers).
An important group of odontological developmental
anomalies involve failure of adequate mineralisation of
the enamel and or dentine. This group includes the four
main subgroups of amelogenesis imperfecta [8, 9], three
types of dentinogenesis imperfecta, two types of dentine
dysplasia and regional odontodysplasia [10, 11].
Caries and pulpitis
The vast majority of disease in the dentoalveolar region
is inflammatory in nature, mostly due to microbial action.
This affects the crowns of the teeth, the roots and their
supporting structures, with effects at a macroscopic level
which may not be easily detected clinically but are usually
well demonstrated radiographically. Caries and periodon-
tal disease are two such important processes in the practice
of dentistry, and imaging is pivotal in their detection, as-
sessment and monitoring during and after treatment.
The carious process is a dynamic condition, initially
causing reversible demineralisation of vulnerable tooth
surfaces beneath dental plaque; an adherent acid-rich
matrix of bacterium-infected debris gathering on dirty
teeth and in undisturbed gingival crevices. The enamel
surface suffers demineralisation, seen as radiolucency,
which progresses to cavitation, followed by bacterial in-
vasion into enamel and subsequently into dentine. Intra-
oral periapical and bitewing radiographs are widely used
to assess this process (Figures 1a,b and 2b). The extent of
loss of healthy enamel and dentine defines the dental
restoration that will be required. Traditionally, teeth were
restored with densely radiopaque amalgam alloy. This
may subsequently be covered by a radiopaque crown of
gold, porcelain or metal/ceramic combinations. More re-
cently tooth-coloured ceramic/resin dental restorations
have gained popularitythese vary in their radiopacity
but are always more radiolucent than amalgam.
The leading front of carious demineralisation may
penetrate deeper, irritating the living pulp within the pulp
chamber, causing reactive secondary dentine to form at the
chamber margin. A rapidly advancing carious lesion may
breach this barrier with acidic infiltrate, causing oedema
within the rigid chamber, leading to inflammation and
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Dentomaxillofacial imaging and interpretation
(a) (b)
(c)
Figure 5. Radiographs illustrating periapical disease. (a)
Periapical radiograph of lower right (LR) 6 showing re-
current caries beneath the distal aspect of the amalgam
restoration and an established apical radiolucency. Also
note the generalised horizontal bone loss and deep vertical
bone defect along the distal aspect of the LR6 root. (b)
Periapical radiograph of crowned LR7 showing an apical
radiolucency and a vertical bone defect along the mesial
aspect of the root. (c) Right sectional panoramic radiograph
showing a radicular cyst at the apex of root-treated LR6.
necrosis of the pulp. Oedema is responsible for the char-
acteristic throbbing toothache of irreversible pulpitis. Ne-
crosis follows, spreading to involve the tissues at the apex
of the root, where oedema initially causes widening of the
apical periodontal ligament (PDL) space.
Periapical pathology
Infiltrating infection from the pulp chamber pro-
gressively destroys local alveolar bone leading to loss of
the sockets cortical margin (the lamina dura), establish-
ing apical periodontitis (Figure 5). The size and margins
of the subsequent lesion indicate its nature. Apical ra-
diolucency becomes visible in acute infection after ap-
proximately 10 days, and is then seen as a slowly
enlarging ill-defined radiolucent area around the apex of
the affected tooth with loss of the lamina dura and PDL
shadow. If the lesion becomes chronic then the resultant
apical granuloma seldom grows greater than 1 cm in di-
ameter and has well-defined, punched-out margins.
Eventually a granuloma may develop into a radicular
cyst, the epithelial lining developing from epithelial
remnants of Hertwigs root sheath in the PDL. Typically
a radicular cyst is well defined and has a corticated out-
line with a diameter normally exceeding 1 cm. Radio-
graphs are used to determine the nature or diagnosis of
imaging.birjournals.org
the apical lesion and thus direct treatment towards root
canal therapy, apical surgery or extraction.
Periodontal disease
Gathering dental plaque initially inflames the margins
of the gingivae, causing local bleeding on tooth brushing
and reversible gingivitis. If untreated, inflammation pro-
gresses to periodontitis, destroying the periodontal at-
tachment between gingiva, PDL and tooth, with plaque
penetrating deep into the developing crevices. Eventually
alveolar bone crests resorb, losing height (horizontal bone
loss) and/or along the root surface of the affected tooth to
create a bony pocket (vertical bone defect), both scenarios
resulting in reduced bony support (Figure 5a,b). Fol-
lowing clinical assessment, radiographs are used exten-
sively in identifying and categorising the type and extent
of alveolar bone destruction, locating contributory fac-
tors such as subgingival calculus or poorly contoured
restorations, and assessing progression and response to
treatment.
Radiolucencies and radiopacities in the jaws
Radiolucencies in the jaws and dentoalveolar region,
identifiable on dental radiographs and cross-sectional
imaging, may be categorised into the following patho-
logical groups:
localised infection
spreading infection
cysts (odontogenic and non-odontogenic)
tumours (odontogenic and non-odontogenic)
giant cell lesions
osseous dysplasias
metabolic and endocrine lesions
idiopathic lesions.
Radiopacities appearing on radiographs of the jaws are
normally of odontogenic or bony origin. Occasionally
opacities may result from superimposed calcification
within the soft tissues or from foreign bodies within or
around the jaws.
It is sometimes more helpful to approach the interpre-
tation of radiolucencies and radiopacities in the maxillo-
facial region by their radiological presentation, rather than
their pathological grouping. The principles of interpre-
tation are applicable to both plain radiographs and cross-
sectional imaging. Radiological features such as a lesions
site, size, shape, outline and effects on adjacent structures
are as applicable here as elsewhere.
Site
Periapical radiolucencies and radiopacities
The most common apical radiolucencies are found in
association with a non-vital tooth and result directly or
indirectly from periapical inflammation. The most com-
mon non-vital tooth is the upper lateral incisor, so the
following lesions are most frequent in this location. In-
flammatory periapical radiolucency ranges from the
acute through chronic to cystic change.
Acute apical periodontitis and abscess formation presents
as an ill-defined apical radiolucency, while chronic
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 J E Brown and B L Thomas

inflammation develops as an apical granuloma (described

above).
The radicular cyst is the most common odontogenic cyst
and forms over the apex of a dead tooth from chronic
irritation of the epithelial cell rests of Malassez, in the
apical PDL, which proliferate to create the lining of this
common dental cyst. It is recognised by its location,
unilocular shape, corticated margin and mildly expansile
behaviour. However, 66% of these round apical radio-
lucencies over 1.5 cm diameter will be radicular cysts, the
reminder mostly representing granulomas (Figure 5c).
Imaging of such cysts over the apex of a maxillary pos-
terior tooth, such as panoramic CT or CBCT, will identify
a bony superior margin of the upwardly displaced antral
floor, and thus help differentiate the odontogenic cyst
from an antral mucous retention cyst. The source of irri-
tation, namely the necrotic dental pulp and debris at the
apex of the tooth, must be removed either by extraction of
the tooth or by root canal treatment with or without
surgical apicectomy, but following this enucleation of the
radicular cyst is curative.
Periapical radiolucencies associated with a vital tooth
may arise from (a)
commonly: the early stages of periapical or florid
osseous dysplasia. These progress to lesions of mixed
radiolucency and opacity (see below).
rarely: malignant lesions such as lymphoma which
may present in alveolar bone associated with a tooth.

Periapical radiopacities usually originate from cemen-

tum or bone. The benign cementoblastoma appears as a round
ball of dense material around the root apex of a vital tooth,
while hypercementosis is a bulbous enlargement in the girth
of a tooth root and apex, particularly associated with older
lone-standing teeth and with Pagets disease.
In alveolar bone the initial reaction to apical in-
flammation is a local reactive osteosclerosis (sclerosing os-
teitis), and it is common to see increased density in the
trabecular bone surrounding chronically infected teeth.
Pericoronal radiolucencies
Dentigerous cysts form from cystic change within the
reduced enamel epithelium found around the crown of
an unerupted tooth. The pericoronal unicystic radiolu-
cency (typically around an unerupted wisdom tooth or
canine) is attached at the cementenamel margin, but can
grow to a large size extending along the jaw, displacing
the originating tooth, causing considerable expansion and
some root resorption of adjacent teeth (Figure 6a). A
dentigerous cyst becomes an eruption cyst as the peri-
coronal cyst emerges into the oral developmental cavity as
a purple/blue swelling through the gingiva. Enucleation is
most commonly used with removal of the causative tooth.
The adenomatoid odontogenic tumour is a rare pericoronal
radiolucency most common around unerupted upper can-
ines, and resembles a dentigerous cyst but with small
intraluminal flecks of radiopacity. This lesion is found in
younger adults, expands and causes neighbouring root re-
sorption. Occasionally other odontogenic tumours and
cysts, such as the ameloblastic fibro-odontoma, calcifying epi-
thelial odontogenic tumour and calcifying odontogenic cyst
(Figure 6b,c), may present as flecked radiolucencies associ-
ated similarly with the crown of an unerupted tooth.
(b) (c)
Figure 6. (a) Cross-sectional cone beam CT (CBCT) recon-
struction passing bucco (left)palatally (right) through
upper right (UR) 1 and URA, and showing a dentigerous
cyst as an expansile pericoronal radiolucency inhibiting
eruption of UR1. (b) Cross-sectional CBCT reconstruction and
(c) parasagittal reconstruction of left mandible showing an
expansile pericoronal radiolucency around unerupted and
inferiorly displaced lower left E containing intrinsic calcifica-
tion typical of a calcifying odontogenic cyst.
Periradicular radiolucencies
Lateral periodontal cysts are small developmental cysts,
typically found between the roots of the lower canine and
first premolar tooth. They may be unicystic or botryoid
(a fine multicystic appearance on histology).
A lateral radicular cyst arises from a necrotic lateral root
canal in an incompletely root-filled tooth and is equiva-
lent to a radicular cyst, though occurring at the lateral
aspect of a non-vital root.
The solitary bone cyst is in fact simply a developmental
cavity containing sparse strands of connective tissue and
sometimes some fluid, and is of unknown aetiology. It is
most common in young people in the body of mandible.
Its characteristic appearance shows it looping up between
the roots of vital teeth but without resorption, and its
margins are well demarcated but not corticated. It may
resolve following curettage or spontaneously regress.

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Dentomaxillofacial imaging and interpretation
(a) (b)
(c)
Figure 7. (a, b) Coronal and sagittal cone beam CT
reconstructions in the maxillary midline showing a small
incisive canal cyst in the inferior portion of the left
incisive canal. (c) Right sectional panoramic illustrating
a Stafnes idiopathic bone cavity below the inferior dental
canal.
Radiolucency associated with an extraction socket
Localised infection within a poorly vascularised or
infected extraction socket is termed dry socket. A local
osteitis may be complicated by retained roots or a bony
sequestration; radiographs are valuable to detect these
and direct treatment.
A residual cyst is left within the alveolus when a ne-
crotic tooth with an associated radicular cyst is removed
but the existing radicular cyst is not enucleated and may
thus persist.
Radiolucency in the anterior palatal midline
This is the characteristic location for the nasopalatine duct
cyst (incisive canal cyst). This non-odontogenic cyst charac-
teristically develops from remnants of respiratory epithe-
lium in the nasopalatine canal, and forms as an inverted
teardrop shaped radiolucency in the palatal midline above
or between the apices of the (vital) upper central incisors,
which may each be displaced laterally (Figure 7a,b).
Table 1. Lesions presenting as loculated or multiloculated radiolucencies within bone
Odontogenic lesions
Keratocystic odontogenic tumour (odontogenic
keratocyst)
Ameloblastoma
Ameloblastic fibroma
Odontogenic myxoma
Glandular odontogenic cyst (sialo-odontogenic cyst)
imaging.birjournals.org
Radiolucencies and radiopacities in relation to the
inferior dental canal
Within the mandible this structure forms a useful de-
marcation between lesions arising from odontogenic tis-
sues [centred above the inferior dental canal (IDC)] and
lesions which are very unlikely to be of odontogenic
origin (centred below the IDC), thus being of bony or
systemic origin. A lesion seen to be arising within the IDC
should be expected to be of neural or vascular origin.
Benign lesions in this location include neuromas, neuro-
fibromas and central haemangiomas. The most important
malignancy to be found along the path of the IDC is
blood-borne metastasis to bone, an ill-defined centrally
destructive lesion found anywhere from the mandibular
foramen to around the mental foramen.
The Stafnes idiopathic bone cavity mimics a cyst, and
is characteristically found below the IDC in the angle
of mandible (Figure 7c). It is, in fact, a developmental
concavity in the medial cortex of the mandible, well dem-
onstrated by cross-sectional imaging. It is well demarcated
and corticated, and may contain fat or submandibular
gland tissue. No treatment is indicated.
Size
The dimensions of a lesion may occasionally help in
distinguishing normal anatomy from developing pa-
thology. A palatal incisive foramen over 6 mm in di-
ameter should raise suspicion of a nasopalatine duct cyst.
The increasing size of a pericoronal radiolucency around
an unerupted tooth should be regarded as suspicious of
dentigerous cyst formation when the follicle exceeds 3 mm
in distance from the crown margin. A well-defined peri-
apical radiolucency over a non-vital tooth which exceeds
1.5 cm diameter is likely to have become a radicular cyst.
Shape
The nasopalatine duct cyst has a characteristic inverted
teardrop shape (see above).
A number of intrabony lesions of the jaws frequently
show a distinctive multilocular/multicystic or septated
appearance, which is helpful in narrowing down the di-
agnosis. These lesions may be divided into three catego-
ries: odontogenic lesions, giant cell lesions and others
(Table 1).
The most common of these lesions, and the most im-
portant to differentiate, are the keratocystic odontogenic
tumour (odontogenic keratocyst) and amelobastoma. The
odontogenic keratocyst has recently been reclassified as
the keratocystic odontogenic tumour in view of its local in-
vasion and high recurrence rate (between 3% and 60%).
It accounts for approximately 211% of jaw cysts. This
Giant cell lesions Others
Central giant cell granuloma Central haemangioma
Cherubism Fibrous dysplasia
Brown tumour of hyperparathyroidism
Aneurysmal bone cyst
7 of 12

(a) (b)
lesion forms, often in place of a wisdom tooth, has
a characteristic mildly loculated outline, and grows by
gentle extension along the jaw but shows little expansion
or root resorption. Its capsule contains satellite cysts, thus
its propensity for recurrence and radiographic review is
recommended (Figure 8a). Odontogenic keratocysts have
high protein (keratin) content; thus, CT numbers may be
higher than for other cysts, ranging from 30 to 200 HU,
and are higher in longstanding, multilocular cysts [12, 13].
The protein component gives a characteristic heteroge-
neous intermediate-to-high signal intensity on T1 weighted
MRI, and variable heterogeneous low-to-high signal in-
tensity on T2 and short-tau inversionrecovery (STIR)
sequences [14]. Large cysts may be marsupialised. Multi-
ple odontogenic keratocysts are found in Gorlins syndrome
(naevoid basal cell carcinoma syndrome) along with
multiple basal cell carcinomas, bifid ribs, calcification of
falx cerebri and hypertelorism.
Ameloblastoma is the most common benign odontogenic
tumour, representing around 1% of oral tumours
a normally highly multilocular/septated radiolucency
more common in older adults, Afro-Caribbean people
and in the angle of mandible, with a marked tendency to
expand buccolingually and cause knife-edged root re-
sorption (Figure 8b). Around 6% of ameloblastomas are
unicystic, and 2% arise peripherally in the oral soft tis-
sues. The more common multilocular type contains
a mixed solid/mulitcystic pathology which can be dis-
tinguished from the unicystic type on MR appearances;
the cystic component shows intermediate signal intensity
on T1 weighted imaging (WI), appears bright on T2 and
STIR images, and does not enhance, while the solid com-
ponent appears as bright foci on T2 WI and will enhance
with gadolinium. The unicystic ameloblastoma may mimic
other odontogenic cysts. Ameloblastomas extend micro-
scopically beyond the plain radiographic margin and are
therefore excised with a margin of normal bone, but over
10% recur even after wide excision. Rare metastasis to
lung is thought to be a complication of surgery. Unicystic
ameloblastomas may be treated more conservatively.
The distinction between odontogenic keratocyst and
ameloblastoma is often by degree of change on plain
radiographs; the odontogenic keratocyst is indolent,
mildly septated, spreads slowly by gentle expansion
along the line of least resistance within a bone to become
ovoid, shows little expansion (normally buccally) and
does not resorb teeth to any extent. By contrast the amelo-
blastoma is highly loculated (soap-bubble or honey-comb
8 of 12
J E Brown and B L Thomas
Figure 8. (a) Right sectional dental
panoramic radiograph of a keratocystic
odontogenic tumour showing mild locu-
lation and little expansion or root re-
sorption. (b) Section of a panoramic
radiograph illustrating an ameloblas-
toma with variable loculation, expan-
sion and marked root resorption.
appearance), highly expansile (both buccally and lin-
gually) and may cause extensive root resorption. Even in
its unicystic form it will both expand aggressively and
resorb teeth. Their internal MRI characteristics are also
helpful; the keratocystic odontogenic tumour is usually
heterogeneous on both T1 and T2 WI owing to keratin
debris, while the ameloblastoma is more uniformly cystic
but with occasional solid enhancing foci both within the
lumen and in the generally thicker wall of the lesion [14].
Other multiloculated odontogenic tumours include the
ameloblastic fibroma (resembling an ameloblastoma, but
found in children) and the odontogenic myxoma (an ag-
gressive odontogenic tumour showing straight septations
which resemble letters such a Z and X). The glandular
odontogenic cyst (sialo-odontogenic cyst) is a locally ag-
gressive, expansile cyst containing mucin-producing cells,
as found in salivary glands. It is more common in the
anterior mandible and in older women.
Giant cell lesions as a group share a predominance of
giant cells as their common histological characteristic.
They share radiological features including a loculated or
septated appearance, a propensity for bone expansion
and displacement of teeth, but without marked root re-
sorption. They include
central giant cell lesion
brown tumour of hyperparathyroidism
jaw lesions of cherubism
aneurysmal bone cyst.
The central giant cell lesion is most commonly found in
young people and in the anterior regions of the jaws.
Aggressive and non-aggressive variants are described,
dependent on degree of expansion, bone thinning and
effects on teeth. They may be treated by local curettage. It
is probable that this is the same entity as the giant cell
tumour of the appendicular skeleton [15].
The brown tumour of hyperparathyroidism is a locally
expansile, loculated haemosiderin-rich lesion (hence the
brown colour) found throughout the skeleton in ap-
proximately 15% of patients with hyperparathyroidism.
Cherubism is a rare condition, which is normally he-
reditary, causing gross bilateral loculated expansion of
the body and rami of the mandible and disrupted de-
velopment and displacement of teeth (Figure 9a,b). Oc-
casionally it may also expand the maxilla and antra. The
characteristic facies resemble a round-cheeked cherub,
and with a heavenward stare achieved by maxillary
Imaging 2013, 22, 20110002
Dentomaxillofacial imaging and interpretation

The term punched out describes a lesion that is well

defined but not corticated. A chronic inflammatory apical
lesion, an apical granuloma, has well-defined margins
which are not corticated. It is seen in post-operative
intrabony sites where fibrous surgical scars have formed,
but it is also notably associated with deposits in myeloma
and eosinophilic granuloma. Eosinophilic granuloma is
a particular mimic of dental disease. It is part of the
group comprising Langerhans cell histiocytosis and may
create punched-out radiolucencies in any area of the
skeleton, but is occasionally encountered in the alveolus,
where an aggressive focus of bone destruction around
a tooth may be mistaken for advanced periodontal
disease.
Ill-defined margins represent invasion or destruction of
marginal bone, so are associated with spreading infection
(a) or malignancy. Infection is by far the most common
process in the dentoalveolar region. The initial reaction to
dental infection is described above. Bone resorption is
followed in time by a local reactive osteosclerosis, and it
is common to see increased density in the trabecular bone
surrounding chronically infected teeth. If this defensive
barrier is overcome, as it may be particularly in those

(b)

Figure 9. (a) Posteroanterior jaws with marked bilateral

multilocular radiolucencies of cherubism affecting the body,
angle and rami of the mandible. (b) Dental panoramic
radiograph of the same patient, with displaced and disor-
dered dental eruption.

expansion, proptosis and increased exposure of the in-

ferior sclera. MRI may be more sensitive than plain films
or CT for assessing intrabony extent. This self-limiting
condition regresses after adolescence but leaves residual
bone distension which may require later surgery to re-
model the facial outline [16]. (a)
An aneurysmal bone cyst is a very rare, expansile locu-
lated or unicystic radiolucency and most commonly
found in the posterior portion of the mandible in young
peopleit is richly vascular and only removed by local
curettage if necessary [17]. Both MR and narrow window-
width CT are useful in showing vascular sinusoidal
locules with blood/plasma fluid levels [18].
Central haemangiomas may be detected clinically by
a bruit on palpation of the expanded jaw, and by blood
oozing from around a deciduous tooth when this is close
to exfoliation. Subsequent tooth exfoliation can lead to
massive blood loss, and children may be admitted as a
surgical emergency. Radiological features of central hae-
mangiomas of the jaws vary widely from well-defined
(b)
radiolucency to irregular, sparsely expanded trabecular
pattern around displaced and resorbed teeth. Figure 10. (a) Right sectional dental panoramic radiograph
of an ill-defined destructive osteomyelitis affecting the
Margins right body of mandible due to bisphosphonate-related
osteonecrosis. (b) Panoramic radiograph showing bilateral
Well-defined and corticated bony margins are seen areas of mixed radiolucency and radiopacity in the
around odontogenic and non-odontogenic cysts, benign posterior body of mandible (arrowed) as a result of florid
tumours and giant cell lesions. fibro-osseous dysplasia.

imaging.birjournals.org 9 of 12

with underlying systemic diseases such as diabetes or
patients on iv or long-term bisphosphonates, then osteo-
myelitis may develop, or bisphosphonate-related osteonec-
rosis in the latter case. Irregular patchy radiolucency
breaching the dense lower border of the mandible and
other cortical plates, and extending into and widening the
IDC are features (Figure 10a). Sequestra may be shed
through the soft tissues into the mouth; and subperiosteal
reactive new bone formation is noted, particularly in
children.
Malignant lesions involve the jaws through local in-
vasion, metastatic spread and (rarely) through primary
development within odontogenic and non-odontogenic
tissues. Metastatic disease frequently spreads via the in-
ferior alveolar artery as secondary deposits along the
route of the IDC. Tumours from breast, bronchus, thy-
roid, kidney, prostate and colon are most frequently en-
countered. Diffusely radiopaque prostate metastases may
mimic reactive osteosclerotic change associated with
dental infection. Direct invasion by oral squamous cell
carcinoma arising in the oral mucosa, gingivae and even
periodontal tissues causes irregular destruction of local
alveolar bone and teeth floating in air; cross-sectional
imaging is essential in assessment.
Osteosarcoma is a rare primary malignancy of bone (7%
of all osteosarcomas) but demonstrates a slightly older
demographic profile (peaking in the fourth decade) than
its equivalent in the appendicular skeleton. It may be
chondroblastic, osteoblastic or fibroblastic. It is twice as
common in men as in women, and 65% are painful at
presentation. Its outline is notable; when the periosteum
is involved spiculated new bone, or sun-ray spiculation,
is seen extending in malignant tissue into adjacent soft
tissues [19].
Malignant transformation within odontogenic cysts
and tumours is a recognised but very rare event, and may
occur in 12% of cysts, giving rise to odontogenic carcino-
mas [20]. In ameloblastomas the exceedingly rare amelo-
blastic carcinoma may develop60 cases have been
reported in the literature. This may metastasise to the
lungs [21, 22].
Internal structure
Lesions may be predominantly radiolucent, predomi-
nantly radiopaque or mixed. The lesions discussed above
have been predominantly radiolucent.
Lesions of mixed radiolucency and radiopacity
Lesions with mixed internal structure form two distinct
groups:
odontogenic tumours
osseous dysplasias (fibro-cemento-osseous dysplasias).
Benign odontogenic tumours may present as radio-
lucencies which demonstrate internal specks and foci of
radiopacity, reflecting their tissues of origin. The most
common in this category is the calcifying epithelial odon-
togenic tumour (CEOT or Pindborg tumour) where central
radiopacities gather in clusters resembling driven snow.
The adenomatoid odontogenic tumour is a pericoronal radio-
lucency which typically develops around unerupted upper
canines, and resembles a dentigerous cyst but with the
10 of 12
J E Brown and B L Thomas
inclusion of small internal radiopacities. The adenomatoid
odontogenic tumour and calcifying cystic odontogenic tumour
are also mixed radiolucent/radiopaque lesions. All typi-
cally expand and cause neighbouring root resorption.
Osseous dysplasias within the jaws all exhibit a pro-
cess of replacement of bone by fibrous connective tissue
matrix, which initially appears radiolucent. Within the
lesion new mineralised foci form which increase in size
and number to coalesce, eventually achieving a pre-
dominantly radiopaque, mature lesion. The radiopaque
material may contain bone or cementum; previous clas-
sifications have termed these fibro-cemento-osseous
lesions, although these tissues are difficult to distin-
guish histologically. The histology of these lesions can
appear similar and therefore radiology plays an impor-
tant part in distinguishing individual variants within this
group. The group includes a spectrum of lesions from
systemic entities such a fibrous dysplasia to osseous dys-
plasias of the jaws, the classification for which was updated
by the World Health Organization in 2005 [23, 24]:
fibrous dysplasia
ossifying fibroma
osseous dysplasias (fibro-cemento-osseous dysplasias)
- periapical osseous dysplasia
- florid osseous dysplasia
- focal osseous dysplasia.
Fibrous dysplasia is normally monostotic and self-
limiting in the jaws, and most commonly affects the
posterior maxilla of young people as a painless expansile
bony mass with fine, ground-glass trabecular pattern
and effacement of lamina dura and other cortical struc-
tures. The lesion blends smoothly into adjacent bone but
may leave marked distortion of the affected jaw.
The ossifying fibroma is a focal, round and very well-
defined lesion of the jaws. It normally grows slowly and
moves towards radiopaque maturation with local ex-
pansion and tooth displacement (with or without some
root resorption). An exception is the juvenile ossifying fi-
broma, which is rapidly growing, more aggressive and
may recur following excision.
Osseous dysplasias are named for their characteristic
pattern; periapical osseous dysplasia presents as several
painless individual radiolucencies beneath the apices of
vital lower anterior teeth. These areas show fine central
foci of mineralisation at an early stage, but in time the
mineralised component increases to create dense irregu-
lar periapical radiopacities. A common error is to un-
dertake root canal therapy on the assumption that these
are apical inflammatory lesions. Focal osseous dysplasia
is a solitary fibro-osseous lesion seen developing be-
neath, and separate from, a tooth. Florid osseous dys-
plasia is a more widespread condition involving
deposits of mixed radiolucency and radiopacity in more
than one quadrant. It frequently involves the mandible
bilaterally, where several round lesions of varying matu-
rity may be seen beneath and around the root apices of
premolar and molar teeth (Figure 10b). This notably affects
middle-aged women of Afro-Caribbean origin.
Radiopaque lesions
Predominantly radiopaque lesions in the jaws may be
of odontogenic origin, bony origin or foreign bodies.
Imaging 2013, 22, 20110002
Dentomaxillofacial imaging and interpretation

Occasionally superimposed calcifications in the soft tis-

sues, such as salivary calculi or phleboliths, may be
mistaken for an intrinsic opacity on plain films, but cross-
sectional imaging or further multidirectional views will
identify their extrabony location.

Radiopacities of odontogenic origin

Most radiopacities originating from odontogenic tis-
sues are moderately or entirely radiopaque, show densi-
ties similar to dental tissues such as cementum, dentine or
enamel and retain essential features such as a peripheral
radiolucent halo equivalent to a periodontal ligament
space. Retained roots and unerupted teeth are frequent
incidental findings; their significance is in acting as a (a)
source of infection, cyst formation or in complicating
dental implant placement in an otherwise edentulous
space. Extra teethsupernumerary teeth (rudimentary and
partially formed teeth, such as mesiodens in the palatal
midline) and supplemental teeth (fully formed extra teeth
similar to those already in the dental arch, such as fourth
molar teeth)are covered above.
Less well-differentiated dental tissue anomalies include
odontomes. These painless hamartomatous growths may
show good histodifferentiation but varying degrees of
morphodifferentiation. The most well differentiated of
this group is the compound odontome; it contains tooth-like
denticles (small tooth-like structures) surrounded by
a radiolucent capsule. The complex odontome is the least (b)
well differentiatedit appears as a heterogeneous mass
of dense dental tissues. Odontomes may replace a tooth Figure 11. (a) Left sectional dental panoramic radiograph
and are mostly found in the anterior maxilla (compound showing knife-edged resorption of molar roots associated
with an ameloblastoma. (b) Section of a panoramic radio-
odontomes) or molar region of the mandible (complex
graph illustrating tooth displacement [lower right (LR) 3
odontomes). arrowed] and root displacement (LR4 and LR2 starred)
The benign cementoblastoma is classified as a tumour associated with a keratocystic odontogenic tumour.
of dental hard tissues and appears as a ball of opaque ma-
terial often closely associated with the apex of a vital tooth.
often in one direction such as buccally, giant cell lesions
and benign odontogenic tumours may expand prolifically
Radiopacities of non-odontogenic origin in both medial and lateral planes. Cysts in the jaws may
Non-odontogenic bony radiopacities range from the expand and thin the cortical plate to the extent that
extremely common developmental dense bone island to clinical palpation reveals eggshell crackling. Displace-
benign tumours of bone such as osteomas and de- ment of other local structures, such as the IDC, is seen in
velopmental lesions such as fibrous dysplasia and ossi- these slowly expansile lesions.
fying fibroma (described above). The nature of a lesion is often indicated by its effects on
The dense bone island is a developmental anomaly: teeth, the most benign lesions, such as cysts and giant cell
a small well-defined area of ectopic cortical bone which lesions, causing gradual tooth displacement, but the more
forms within the trabecular space, often near the apices aggressive lesions, such as tumours and infected cysts,
in the molar or premolar regions of the mandible. It causing tooth resorption. Knife-edge resorption is par-
requires no intervention but may complicate dental ticularly associated with tumours (Figure 11a,b). Teeth
extractions. seen floating in air is also a feature associated with ag-
Osteomas arise peripherally, generally from the man- gressive and rapid alveolar bone destruction, but should
dibular cortex as single pedunculated or sessile cortical or not be confused with advanced periodontal disease;
mixed cortical and medullary expansile bony masses. therefore, the periodontal condition of remaining dentition
Multiple jaw osteomas may be found in Gardners syn- should be taken into account.
drome (familial adenomatous polyposis syndrome). The role of this article is to assist the radiologist
Mature osseous dysplasias may contain both dental tis- in bringing together and processing the diagnostic
sues and bone elements and will also cause radiopacity; information gained through the identification of the
these have been described above. features described above, and to develop a differential
diagnosis that will have relevance to the dentist and
Effects on adjacent structures maxillofacial surgeon.
Bone expansion is a phenomenon seen to varying
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