Ebook Diagnostic imaging oral and maxillofacial: Part 1

Diagnostic Imaging Oral and
Maxillofacial


Diagnostic Imaging Oral and Maxillofacial

Table of Contents
Diagnostic Imaging - Oral and Maxillofacial .................................................................................................. 9
Cover ....................................................................................................................................................... 9
Authors.................................................................................................................................................... 9
Dedication ..............................................................................................................................................11
Preface ...................................................................................................................................................12
Acknowledgements ................................................................................................................................12
Part I - Anatomy......................................................................................................................................13
Section 1 - Oral Cavity .........................................................................................................................13
1. Teeth ..........................................................................................................................................13
2. Dental Restorations .....................................................................................................................24
3. Dental Implants ...........................................................................................................................31
4. Maxilla ........................................................................................................................................44
5. Mandible.....................................................................................................................................51
6. Tongue ........................................................................................................................................59
7. Retromolar Trigone .....................................................................................................................63
8. Sublingual Space .........................................................................................................................68
9. Submandibular Space ..................................................................................................................73
10. Oral Mucosal Space - Surface.....................................................................................................78
Section 2 - Nose and Sinuses ...............................................................................................................81
11. Sinonasal Overview ...................................................................................................................81
12. Ostiomeatal Complex ................................................................................................................96
13. Pterygopalatine Fossa .............................................................................................................101
Section 3 - Temporal Bone ................................................................................................................107
14. Temporomandibular Joint .......................................................................................................107

15. External, Middle, and Inner Ear ...............................................................................................113
Section 4 - Base of Skull ....................................................................................................................120
16. Anterior Skull Base ..................................................................................................................120
17. Central Skull Base ....................................................................................................................127
18. Styloid Process and Stylohyoid Ligament .................................................................................134
Section 5 - Cranial Nerves .................................................................................................................140
19. Cranial Nerve 5 ........................................................................................................................140
20. Cranial Nerve 7 ........................................................................................................................153
Section 6 - Cervical Spine ..................................................................................................................162
21. Craniocervical Junction ............................................................................................................162
Section 7 - Suprahyoid Neck ..............................................................................................................173
22. Suprahyoid Neck Overview ......................................................................................................173
23. Parapharyngeal Space .............................................................................................................180
24. Nasopharynx and Oropharynx .................................................................................................185
25. Masticator Space .....................................................................................................................192
26. Parotid Space ..........................................................................................................................197
27. Carotid Space ..........................................................................................................................202
28. Retropharyngeal Space............................................................................................................207
29. Perivertebral Space .................................................................................................................212
30. Lymph Nodes ..........................................................................................................................217
31. External and Internal Carotid Arteries......................................................................................222
Part II - Diagnoses .................................................................................................................................230
Section 1 - Teeth ...............................................................................................................................230
I. Developmental Alterations in Size and Shape of Teeth ...............................................................230
32. Hypodontia..........................................................................................................................230
33. Hyperdontia ........................................................................................................................233
34. Macrodontia, Gemination, and Fusion .................................................................................236
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Diagnostic Imaging Oral and Maxillofacial
35. Microdontia .........................................................................................................................239
36. Concrescence ......................................................................................................................240
37. Talon Cusp ...........................................................................................................................242
38. Dens Invaginatus .................................................................................................................243
39. Enamel Pearls ......................................................................................................................245
40. Taurodontism ......................................................................................................................246
41. Dilaceration .........................................................................................................................248
42. Supernumerary Roots ..........................................................................................................249
II. Developmental Alterations in Structure of Teeth .......................................................................251
43. Amelogenesis Imperfecta ....................................................................................................251
44. Dentinogenesis Imperfecta ..................................................................................................257
45. Dentin Dysplasia ..................................................................................................................261
46. Regional Odontodysplasia....................................................................................................262
III. Acquired Alterations of Teeth and Supporting Structures .........................................................264
47. Attrition...............................................................................................................................264
48. Abrasion ..............................................................................................................................267
49. Erosion ................................................................................................................................269
50. Abfraction ...........................................................................................................................270
51. Turner Dysplasia ..................................................................................................................272
52. Internal and External Resorption .........................................................................................274
53. Hypercementosis .................................................................................................................280
IV. Trauma ....................................................................................................................................282
54. Concussion ..........................................................................................................................282
55. Luxation ..............................................................................................................................284
56. Root Fractures .....................................................................................................................289
V. Infection - Inflammation............................................................................................................293
57. Dental Caries .......................................................................................................................293
58. Periapical Rarefying Osteitis ................................................................................................298
59. Periapical Sclerosing Osteitis................................................................................................305

60. Periodontal Disease .............................................................................................................308
VI. Miscellaneous ..........................................................................................................................317
61. Gubernaculum Dentis ..........................................................................................................317
Section 2 - Oral Cavity .......................................................................................................................320
I. Congenital - Genetic ...................................................................................................................320
62. Submandibular Space Accessory Salivary Tissue...................................................................320
63. Lingual Thyroid ....................................................................................................................323
64. Dermoid and Epidermoid Cysts ............................................................................................326
65. Lymphatic Malformation .....................................................................................................333
66. Submandibular Gland Aplasia-Hypoplasia ............................................................................339
67. Foregut Duplication Cyst in Tongue .....................................................................................343
II. Infection....................................................................................................................................346
68. Oral Cavity Soft Tissue Infections .........................................................................................346
III. Inflammation............................................................................................................................352
69. Ranula .................................................................................................................................352
70. Submandibular Gland Sialadenitis ........................................................................................358
71. Oral Cavity Sialocele ............................................................................................................362
72. Submandibular Gland Mucocele ..........................................................................................365
IV. Neoplasm, Benign ....................................................................................................................368
73. Sublingual Gland Benign Mixed Tumor.................................................................................368
74. Submandibular Gland Benign Mixed Tumor .........................................................................371
75. Palate Benign Mixed Tumor .................................................................................................375
V. Neoplasm, Malignant ................................................................................................................378
76. Oral Cavity Minor Salivary Gland Malignancy .......................................................................378
77. Sublingual Gland Carcinoma ................................................................................................381
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Diagnostic Imaging Oral and Maxillofacial
78. Submandibular Gland Carcinoma .........................................................................................385

79. Submandibular Space Nodal Non-Hodgkin Lymphoma .........................................................388
80. Oral Tongue SCCa ................................................................................................................391
81. Floor of Mouth SCCa ............................................................................................................398
82. Gingival SCCa .......................................................................................................................401
83. Retromolar Trigone SCCa .....................................................................................................404
84. Submandibular Space Nodal SCCa........................................................................................408
85. Buccal Mucosa SCCa ............................................................................................................411
86. Hard Palate SCCa .................................................................................................................414
VI. Miscellaneous - Idiopathic ........................................................................................................417
87. Motor Denervation CN12.....................................................................................................417
88. Submandibular Sialoliths .....................................................................................................421
Section 3 - Mandible and Maxilla ......................................................................................................424
I. Normal Variants .........................................................................................................................424
89. Buccal and Palatal Exostoses ................................................................................................424
90. Torus Mandibularis ..............................................................................................................427
91. Torus Palatinus ....................................................................................................................430
92. Accessory Mandibular Canal ................................................................................................433
93. Mandibular Salivary Gland Defect ........................................................................................436
94. Mandible-Maxilla Idiopathic Osteosclerosis .........................................................................442
II. Congenital - Genetic ..................................................................................................................445
95. Clefts ...................................................................................................................................445
96. Cleidocranial Dysplasia ........................................................................................................448
97. Pierre Robin Sequence .........................................................................................................452
98. Treacher Collins Syndrome ..................................................................................................455
III. Trauma.....................................................................................................................................458
99. Mandible Fracture ...............................................................................................................458
100. Nasoethmoid Complex Fracture.........................................................................................464
101. Complex Midfacial Fracture ...............................................................................................468
102. Zygomaticomaxillary Complex Fracture .............................................................................471
103. Trans-facial Fracture ..........................................................................................................474

IV. Infection - Inflammation...........................................................................................................479
104. Mandible-Maxilla Osteomyelitis.........................................................................................479
105. Mandible-Maxilla Osteoradionecrosis ................................................................................485
106. Mandible-Maxilla Osteonecrosis ........................................................................................491
V. Cysts, Odontogenic ...................................................................................................................498
107. Dentigerous Cyst ...............................................................................................................498
108. Lateral Periodontal Cyst .....................................................................................................504
109. Residual Cyst .....................................................................................................................508
110. Buccal Bifurcation Cyst ......................................................................................................511
VI. Cysts, Nonodontogenic ............................................................................................................517
111. Mandible-Maxilla Aneurysmal Bone Cyst ...........................................................................517
112. Nasopalatine Duct Cyst ......................................................................................................523
113. Nasolabial Cyst ..................................................................................................................530
114. Mandible-Maxilla Simple Bone Cyst ...................................................................................533
VII. Fibro-osseous Lesions .............................................................................................................539
115. Periapical Cemental Dysplasia............................................................................................539
116. Florid Cemento-osseous Dysplasia .....................................................................................546
117. Cemento-ossifying Fibroma ...............................................................................................552
118. Mandible-Maxilla Fibrous Dysplasia ...................................................................................558
119. Paget Disease ....................................................................................................................564
120. Cherubism .........................................................................................................................570
VIII. Neoplasm, Benign, Odontogenic ............................................................................................577
121. Odontoma .........................................................................................................................577
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Diagnostic Imaging Oral and Maxillofacial
122. Adenomatoid Odontogenic Tumor.....................................................................................583
123. Ameloblastoma .................................................................................................................586
124. Ameloblastic Fibroma ........................................................................................................592

125. Ameloblastic Fibro-odontoma............................................................................................598
126. Calcifying Epithelial Odontogenic Tumor ............................................................................601
127. Calcifying Cystic Odontogenic Tumor .................................................................................604
128. Cementoblastoma .............................................................................................................607
129. Odontogenic Myxoma .......................................................................................................611
130. Central Odontogenic Fibroma ............................................................................................614
131. Keratocystic Odontogenic Tumor .......................................................................................617
132. Basal Cell Nevus Syndrome ................................................................................................624
IX. Neoplasm, Benign, Nonodontogenic ........................................................................................627
133. Central Hemangioma .........................................................................................................627
134. Osteoid Osteoma ...............................................................................................................630
135. Osteoblastoma ..................................................................................................................634
136. Mandible-Maxilla Osteoma ................................................................................................637
137. Nerve Sheath Tumor ..........................................................................................................640
138. Neurofibromatosis Type 1..................................................................................................646
139. Desmoplastic Fibroma .......................................................................................................653
X. Neoplasm, Malignant, Odontogenic ..........................................................................................656
140. Malignant Ameloblastoma and Ameloblastic Carcinoma ....................................................656
XI. Neoplasm, Malignant, Nonodontogenic ...................................................................................659
141. Mandible-Maxilla Metastasis .............................................................................................659
142. Mandible-Maxilla Osteosarcoma .......................................................................................668
143. Mandible-Maxilla Chondrosarcoma ...................................................................................674
144. Primary Intraosseous Carcinoma........................................................................................680
145. Central Mucoepidermoid Carcinoma .................................................................................683
146. Burkitt Lymphoma .............................................................................................................686
147. Non-Hodgkin Lymphoma ...................................................................................................692
148. Multiple Myeloma .............................................................................................................698
149. Ewing Sarcoma ..................................................................................................................705
150. Leukemia ...........................................................................................................................711
XII. Tumor-like Lesions ..................................................................................................................715

151. Mandible-Maxilla Central Giant Cell Granuloma.................................................................715
152. Langerhans Histiocytosis ....................................................................................................721
Section 4 - Temporomandibular Joint................................................................................................728
I. Congenital Disorders ..................................................................................................................728
153. Condylar Aplasia ................................................................................................................728
154. Hemifacial Microsomia ......................................................................................................731
II. Developmental Acquired Disorders ...........................................................................................737
155. Condylar Hyperplasia .........................................................................................................737
156. Coronoid Hyperplasia ........................................................................................................747
157. Condylar Hypoplasia ..........................................................................................................750
158. Fibrous Ankylosis ...............................................................................................................756
159. Bony Ankylosis ...................................................................................................................759
III. Trauma.....................................................................................................................................762
160. TMJ Fracture......................................................................................................................762
161. Dislocation.........................................................................................................................765
162. Bifid Condyle .....................................................................................................................768
163. TMJ Osteochondritis Dissecans ..........................................................................................774
IV. Inflammatory Disorders ...........................................................................................................777
164. TMJ Rheumatoid Arthritis ..................................................................................................777
165. TMJ Juvenile Idiopathic Arthritis ........................................................................................780
166. TMJ Pigmented Villonodular Synovitis ...............................................................................786
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Diagnostic Imaging Oral and Maxillofacial
V. Degenerative Disorders .............................................................................................................789
167. TMJ Degenerative Disease .................................................................................................789
168. TMJ Synovial Cyst ..............................................................................................................795
169. Condylysis..........................................................................................................................798
VI. Disc Derangement Disorders ....................................................................................................807

170. Disc Displacement with Reduction .....................................................................................807
171. Disc Displacement without Reduction ................................................................................811
172. Adhesions ..........................................................................................................................814
VII. Neoplasm, Benign ...................................................................................................................817
173. TMJ Osteoma.....................................................................................................................817
174. TMJ Osteochondroma........................................................................................................820
VIII. Tumor-like Lesions .................................................................................................................826
175. TMJ Calcium Pyrophosphate Dihydrate Deposition Disease ...............................................826
176. TMJ Synovial Chondromatosis ...........................................................................................833
IX. Neoplasm, Malignant ...............................................................................................................839
177. TMJ Osteosarcoma ............................................................................................................839
178. TMJ Chondrosarcoma ........................................................................................................842
179. TMJ Metastasis ..................................................................................................................848
X. Miscellaneous ...........................................................................................................................851
180. TMJ Simple Bone Cyst ........................................................................................................851
181. TMJ Aneurysmal Bone Cyst ................................................................................................854
Section 5 - Maxillary Sinus and Nasal Cavity ......................................................................................857
I. Normal Variants .........................................................................................................................857
182. Deviated Nasal Septum ......................................................................................................857
183. Concha Bullosa ..................................................................................................................859
184. Accessory Ostia..................................................................................................................860
II. Developmental ..........................................................................................................................863
185. Hypoplasia-Aplasia ............................................................................................................863
III. Inflammation............................................................................................................................869
186. Mucus Retention Pseudocyst .............................................................................................869
187. Sinonasal Mucocele ...........................................................................................................873
188. Sinonasal Wegener Granulomatosis ...................................................................................879
189. Sinonasal Polyposis ............................................................................................................885
190. Acute Rhinosinusitis...........................................................................................................892
191. Chronic Rhinosinusitis ........................................................................................................898

192. Odontogenic Sinusitis ........................................................................................................904
193. Allergic Fungal Sinusitis ......................................................................................................907
194. Invasive Fungal Sinusitis.....................................................................................................910
195. Mycetoma .........................................................................................................................916
196. Invasive Pseudotumor .......................................................................................................920
IV. Neoplasm, Benign ....................................................................................................................923
197. Sinonasal Inverted Papilloma .............................................................................................923
198. Sinonasal Ossifying Fibroma...............................................................................................929
199. Sinonasal Osteoma ............................................................................................................935
V. Neoplasm, Malignant ................................................................................................................941
200. Sinonasal Squamous Cell Carcinoma ..................................................................................941
201. Sinonasal Adenoid Cystic Carcinoma ..................................................................................945
202. Nasopharyngeal Carcinoma ...............................................................................................948
203. Sinonasal Malignant Melanoma .........................................................................................954
VI. Tumor-like Lesions ...................................................................................................................958
204. Sinonasal Fibrous Dysplasia ...............................................................................................958
Section 6 - Masticator Space .............................................................................................................964
I. Normal Variants .........................................................................................................................964
205. Pterygoid Venous Plexus Asymmetry .................................................................................964
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Diagnostic Imaging Oral and Maxillofacial
II. Infection....................................................................................................................................967
206. Masticator Space Abscess ..................................................................................................967
III. Degenerative ............................................................................................................................973
207. Masticator Muscle Atrophy................................................................................................973
IV. Neoplasm, Benign ....................................................................................................................980
208. Masticator Space CNV3 Schwannoma ................................................................................980
209. Fibromatosis ......................................................................................................................983

V. Neoplasm, Malignant ................................................................................................................989
210. Masticator Space Chondrosarcoma ....................................................................................989
211. Masticator Space Sarcoma .................................................................................................993
212. Masticator Space CNV3 Perineural Tumor..........................................................................999
VI. Miscellaneous - Idiopathic ...................................................................................................... 1005
213. Benign Masticator Muscle Hypertrophy ........................................................................... 1005
Section 7 - Parotid Space ................................................................................................................. 1009
I. Inflammatory ........................................................................................................................... 1009
214. Parotid Sialadenitis .......................................................................................................... 1009
215. Parotid Sialoliths .............................................................................................................. 1012
216. Benign Lymphoepithelial Lesions-HIV............................................................................... 1015
II. Neoplasm, Benign ................................................................................................................... 1021
217. Parotid Benign Mixed Tumor ........................................................................................... 1021
218. Warthin Tumor ................................................................................................................ 1027
219. Parotid Schwannoma ....................................................................................................... 1033
III. Neoplasm, Malignant ............................................................................................................. 1037
220. Parotid Malignant Mixed Tumor ...................................................................................... 1037
221. Parotid Mucoepidermoid Carcinoma ............................................................................... 1040
222. Parotid Adenoid Cystic Carcinoma ................................................................................... 1046
223. Parotid Non-Hodgkin Lymphoma ..................................................................................... 1049
224. Metastatic Disease of Parotid Nodes................................................................................ 1055
IV. Autoimmune .......................................................................................................................... 1061
225. SjoGren Syndrome ........................................................................................................... 1061
Part III - Differential Diagnoses............................................................................................................ 1064
Section 1 - Teeth ............................................................................................................................. 1064
I. Alterations in Tooth Number .................................................................................................... 1064
226. Extra Teeth ...................................................................................................................... 1064
227. Missing Teeth .................................................................................................................. 1069
II. Alterations in Tooth Morphology - Shape ................................................................................ 1073
228. Crown Changes ................................................................................................................ 1073

229. Root Changes................................................................................................................... 1077
Section 2 - Mandible and Maxilla .................................................................................................... 1085
I. Alterations in Supporting Structures of Teeth ........................................................................... 1085
230. Periapical Radiolucencies ................................................................................................. 1085
231. Periapical Radiopacities and Mixed Lesions ...................................................................... 1093
232. Floating Teeth.................................................................................................................. 1097
233. Widened Periodontal Ligament Space .............................................................................. 1101
234. Lamina Dura Changes ...................................................................................................... 1106
II. Radiolucencies ........................................................................................................................ 1113
235. Well-defined Unilocular Radiolucencies ........................................................................... 1113
236. Pericoronal Radiolucencies without Radiopacities............................................................ 1121
237. Pericoronal Radiolucencies with Radiopacities ................................................................. 1126
238. Multilocular Radiolucencies ............................................................................................. 1131
239. Ill-defined Radiolucencies ................................................................................................ 1138
240. Generalized Rarefaction .................................................................................................. 1148
III. Radiopacities .......................................................................................................................... 1156
241. Well-defined Radiopacities .............................................................................................. 1156
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Diagnostic Imaging Oral and Maxillofacial
242. Ground-Glass and Granular Radiopacities ........................................................................ 1164
243. Generalized Radiopacities ................................................................................................ 1171
IV. Periosteal Reactions ............................................................................................................... 1176
244. Periosteal Reactions ........................................................................................................ 1176
Section 3 - Oral Cavity ..................................................................................................................... 1186
I. Anatomically Based Lesions ...................................................................................................... 1186
245. Submandibular Space Lesions .......................................................................................... 1186
246. Parotid Space Lesions ...................................................................................................... 1194
247. Sublingual Space Lesions.................................................................................................. 1202

248. Oral Mucosal Space-Surface Lesions ................................................................................ 1209
249. Root of Tongue Lesions .................................................................................................... 1217
II. Miscellaneous ......................................................................................................................... 1224
250. Soft Tissue Calcifications .................................................................................................. 1224
Section 4 - Temporomandibular Joint.............................................................................................. 1232
I. Changes in Condylar Size and Function ..................................................................................... 1232
251. Small Condyle .................................................................................................................. 1232
252. Large Condyle .................................................................................................................. 1240
253. Limited Condylar Translation ........................................................................................... 1248
II. Mass Lesions ........................................................................................................................... 1255
254. TMJ Radiolucencies.......................................................................................................... 1255
255. TMJ Radiopacities ............................................................................................................ 1259
III. Miscellaneous ........................................................................................................................ 1264
256. TMJ Articular Loose Bodies .............................................................................................. 1264
Section 5 - Maxillary Sinus and Nasal Cavity .................................................................................... 1268
I. Nasal Lesions............................................................................................................................ 1268
257. Perforated Nasal Septum ................................................................................................. 1268
258. Nasal Lesion without Bony Destruction ............................................................................ 1272
259. Nasal Lesion with Bony Destruction ................................................................................. 1280
260. Sinonasal Fibro-osseous and Cartilaginous Lesions........................................................... 1287
II. Sinus Lesions ........................................................................................................................... 1291
261. Paranasal Sinus Lesions without Bony Destruction ........................................................... 1291
262. Paranasal Sinus Lesions with Bony Destruction ................................................................ 1299
III. Miscellaneous ........................................................................................................................ 1307
263. Displaced Dental Structures into Antrum ......................................................................... 1307
Index .................................................................................................................................................. 1312
A ..................................................................................................................................................... 1312
B ..................................................................................................................................................... 1313
C ..................................................................................................................................................... 1314
D ..................................................................................................................................................... 1317

E ..................................................................................................................................................... 1318
F ..................................................................................................................................................... 1319
G..................................................................................................................................................... 1320
H..................................................................................................................................................... 1320
I ...................................................................................................................................................... 1321
J ...................................................................................................................................................... 1321
K ..................................................................................................................................................... 1322
L ..................................................................................................................................................... 1322
M .................................................................................................................................................... 1323
N..................................................................................................................................................... 1327
O..................................................................................................................................................... 1328
P ..................................................................................................................................................... 1332
Q .................................................................................................................................................... 1335
R ..................................................................................................................................................... 1335
S ..................................................................................................................................................... 1336
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Diagnostic Imaging Oral and Maxillofacial
T ..................................................................................................................................................... 1341
U..................................................................................................................................................... 1343
V ..................................................................................................................................................... 1343
W.................................................................................................................................................... 1343
Z ..................................................................................................................................................... 1343

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Diagnostic Imaging Oral and Maxillofacial

Diagnostic Imaging - Oral and Maxillofacial
Cover

Authors
Authors
Lisa J. Koenig BChD, DDS, MS
Associate Professor
Program Director, Oral Medicine and Oral Radiology
Marquette University School of Dentistry
Milwaukee, WI
C. Grace Petrikowski DDS, MSc, FRCD(C)
Associate Professor
Department of Oral Radiology
Faculty of Dentistry
University of Toronto
Toronto, Canada
Dania Tamimi BDS, DMSc
Oral and Maxillofacial Radiology Consultant
Private Practice
Orlando, FL
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Diagnostic Imaging Oral and Maxillofacial
H. Ric Harnsberger MD
Professor
Department of Radiology and Otolaryngology
R.C. Willey Chair in Neuroradiology
University of Utah School of Medicine
Salt Lake City, UT

Axel Ruprecht DDS, MScD, FRCD(C)
Gilbert E. Lilly Professor of Diagnostic Sciences
Professor and Director of Oral and Maxillofacial Radiology
Department of Oral Pathology, Radiology, and Medicine
Professor of Radiology; Anatomy and Cell Biology
University of Iowa
Iowa City, IA
Byron W. Benson DDS, MS
Professor and Vice Chair
Department of Diagnostic Sciences
Texas A&M Health Science Center
Baylor College of Dentistry
Dallas, TX
Margot L. Van Dis DDS, MS
Professor
Department of Oral Pathology, Medicine, and Radiology
Indiana University School of Dentistry
Indianapolis, IN
David Hatcher DDS, MSc
Adjunct Associate Clinical Professor
University of Pacific
Radiologist
Diagnostic Digital Imaging
Sacramento, CA
Susanne E. Perschbacher DDS, MSc, FRCD(C)
Assistant Professor
Department of Oral Radiology
Faculty of Dentistry
University of Toronto
Toronto, Canada

P.vii

CONTRIBUTING AUTHORS
Michelle A. Michel, MD
Professor of Radiology and Otolaryngology
Chief, Head and Neck Neuroradiology
Medical College of Milwaukee
Milwaukee, WI
Christine M. Glastonbury, MBBS
Associate Professor of Radiology and Biomedical Imaging,
Otolaryngology - Head and Neck Surgery, and Radiology
Oncology
University of California, San Francisco
San Francisco, CA
Richard H. Wiggins, III, MD
Associate Professor
Department of Radiology, Otolaryngology - Head and Neck
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Diagnostic Imaging Oral and Maxillofacial
Surgery, and Biomedical Informatics
University of Utah School of Medicine
Salt Lake City, UT
Hilda E. Stambuk, MD
Associate Attending of Radiology
Clinical Head of Head and Neck Imaging
Memorial Sloan - Kettering Cancer Center
Associate Professor of Radiology
Weill Medical College of Cornell University

New York, NY
Deborah R. Shatzkes, MD
Associate Professor of Radiology
Columbia University College of Physicians and Surgeons
Director of Head and Neck Imaging
St. Lukes - Roosevelt Hospital Center
New York, NY
Barton F. Branstetter, IV, MD
Professor of Radiology, Otolaryngology,
and Biomedical Informatics
University of Pittsburgh School of Medicine
Director of Head and Neck Imaging
University of Pittsburgh Medical Center
Pittsburgh, PA
Rebecca S. Cornelius, MD
Professor of Radiology and Otolaryngology - Head
and Neck Sugery
University of Cincinnati College of Medicine
University Hospital - UC Health
Cincinnati, OH
Bernadette L. Koch, MD
Professor of Radiology and Pediatrics
University of Cincinnati College of Medicine
Associate Director of Physician Services and Education
Cincinnati Children's Hospital Medical Center
Cincinnati, OH
Kristine M. Mosier, DMD, PhD
Associate Professor of Radiology
Chief, Head and Neck Radiology
Indiana University

Department of Radiology and Imaging Sciences
Indianapolis, IN
Caroline D. Robson, MBChB
Associate Professor of Radiology
Harvard Medical School
Operations Vice Chair, Radiology
Director of Head and Neck Imaging
Children's Hospital, Boston
Boston, MA

Dedication
“No man is an island” as the quotation goes. So it is with this compilation, which is the result of the
combined efforts of the intrepid group of authors, Axel, Dania, David, Grace, Margot, Pete, Ric, and
Susanne, who embarked on this journey with me almost two years ago. Many thanks are owed to them for
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Diagnostic Imaging Oral and Maxillofacial
their dedication and hard work. A special thanks is due to Dania Tamimi whose insight and vision was the
original inspiration for this book and who has been a source of wisdom and support throughout the writing.
We are grateful to the many colleagues who shared images with us, but I wish to recognize two in
particular, Mansur Ahmad and Marcel Noujeim, who gave generously from their libraries and whose
images feature frequently in this tome.
Many thanks to Kellie Heap at Amirsys who possesses saint-like patience and who was unbelievably helpful
and the glue that held our team together. And to Ric Harnsberger, what can I say? Thank you, thank you,
for having faith in me and giving me this incredible opportunity. It has been an honor and a pleasure to
work with the remarkably talented people at Amirsys.
Lastly, thanks to my family, Karl, Sophie, Ben, Natalie, Alex, and Jack for their patience and understanding.
And to Jack in particular: Your mom is back … put the X-box away. :-)
LJK

Preface
It is with great pleasure that we present to you this first edition of the Diagnostic Imaging series dedicated
to oral and maxillofacial radiology. The book was written by oral and maxillofacial radiologists and offers a
dentist's perspective on oral and maxillofacial imaging with complete and accurate dental anatomy and
nomenclature, as well as findings that affect the many aspects of dental treatment. This book differs from
the traditional Diagnostic Imaging format in that it contains anatomy, diagnoses, and differential diagnoses
sections within the same volume.
Anatomy section: The 31 chapters in this section cover the spectrum of oral and maxillofacial anatomy
from embryology of the teeth to carotid arteries. Each chapter is extensively illustrated with the
extraordinary graphics that have become synonymous with the Amirsys name. The inclusion of this section
underscores our belief that a comprehensive knowledge of the anatomy of the region is an essential
component of the radiographic interpretation process.
Diagnoses section: This section contains 185 chapters organized within anatomically oriented subdivisions
beginning with conditions affecting the teeth and ending with parotid space lesions. Included in this section
is an extensive collection of temporomandibular joint disorders. While scarcity of images did not allow us
to include some of the more esoteric diagnoses, we think you will find all of the common and most of the
not-so common lesions encountered in the oral and maxillofacial region.
Differential diagnoses section: There are 38 chapters included in this section, which offers a unique and
intuitive method for interpreting pathology according to radiographic appearance.
This is an image-rich textbook, containing over 2,300 images in print, and offers the reader a
comprehensive review of the oral and maxillofacial complex. Whenever possible and appropriate, conebeam CT (CBCT) and CT images have been included to illustrate the three-dimensional aspects of the
anatomy and pathology. The electronic version of the book contains many, many more images, as well as
information that was excluded from the print book because of space constraints. The electronic version
also allows for linking between chapters, allowing the reader to easily navigate between the different
sections of the book.
We trust that this textbook will serve as a useful tool to both the neophyte and the seasoned radiologist, as
well as those dental specialists or general practitioners who are currently using CT and/or CBCT technology
or anticipate using this technology in the future. Medical radiologists with an interest in the oral and
maxillofacial region will find this book a valuable companion to Diagnostic Imaging: Head and Neck, Second

Edition.
Lisa J. Koenig, BChD, DDS, MS
Associate Professor
Program Director, Oral Medicine and Oral Radiology
Marquette University School of Dentistry
Milwaukee, WI

Acknowledgements
Text Editing
Dave L. Chance, MA
12


Diagnostic Imaging Oral and Maxillofacial
Arthur G. Gelsinger, MA
Matthew R. Connelly, MA
Lorna Morring, MS
Rebecca L. Hutchinson, BA
Angela M. Green, BA
Image Editing
Jeffrey J. Marmorstone, BS
Lisa A. Magar, BS
Medical Editing
Rumpa Ganguly, BDS, MS
Fatima Jadu, DDS
Illustrations
Richard Coombs, MS
Lane R. Bennion, MS
Laura C. Sesto, MA
Wes Price, MS, CMI

Art Direction and Design
Laura C. Sesto, MA
Mirjam Ravneng
Associate Editor
Ashley R. Renlund, MA
Publishing Lead
Kellie J. Heap, BA

Part I - Anatomy
Section 1 - Oral Cavity
1. Teeth
TERMINOLOGY
Abbreviations
 Incisor (Inc), canine (C), premolar (PM), molar (M)
Synonyms
 Cuspid = canine
 Bicuspid = premolar
IMAGING ANATOMY
Overview
 Humans have 2 dentitions: Primary and permanent
 Teeth are divided into maxillary (upper) and mandibular (lower)
 Each jaw is divided into 2 quadrants: Right and left separated by midline
 Each quadrant has 5 primary and 8 permanent teeth
o Primary: 2 incisors (central and lateral), 1 canine, 2 molars (1st and 2nd)
o Permanent: 2 incisors (central and lateral), 1 C, 2 PM (1st and 2nd), 3 M (1st, 2nd, and 3rd)
 Teeth can be named or numbered
 Naming teeth should follow this sequence: Dentition → jaw → side → tooth name
o Example: Primary maxillary right 1st molar; permanent mandibular left canine
o Exceptions are premolars and 3rd molars: Only present in permanent dentition, so no need
to use “permanent”

o If only permanent teeth are present (all primary teeth have been exfoliated), no need to
use “permanent”
 Numbering teeth depends on country
o Most countries use FDI system for numbering
 Quadrants are numbered
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Diagnostic Imaging Oral and Maxillofacial


Permanent: Upper right (UR) = 1, upper left (UL) = 2, lower left (LL) = 3, lower right
(LR) = 4
 Primary: Upper right (UR) = 5, upper left (UL) = 6, lower left (LL) = 7, lower right (LR)
=8
 Teeth are numbered
 Permanent: Central Inc = 1, lateral Inc = 2, C = 3, 1st PM = 4, 2nd PM = 5, 1st M = 6,
2nd M = 7, 3rd M=8
 Primary: Central Inc = 1, lateral Inc = 2, C = 3, 1st M = 4, 2nd M = 5
 Example: Permanent mandibular right 1st M = tooth #46 (pronounced “four-six”)
o United States uses universal system
 Only teeth are numbered
 Permanent teeth start with #1 (maxillary right 3rd M) and go to #16 (maxillary left
3rd M) pronounced “sixteen”
 Mandibular left 3rd M is #17 (seventeen) and goes to mandibular right 3rd M #32
(thirty-two)
 Primary teeth are labeled with letters A → T starting with last molar on upper right:
UR → UL→ LL → LR
o Other tooth numbering systems exist; check with local dental organization
o When in doubt, describe teeth by name

Anatomy Relationships
 When describing teeth or objects in relation to teeth, conventional anatomic positions (inferior,
posterior, medial, lateral, anterior, posterior) are not used
 Position is described in relation to
o Midline of arch (i.e., line between central incisors), not anatomical midline
 All surfaces of teeth that are in direction of midline of arch are “mesial”
 All surfaces of teeth away from midline of arch are “distal”
o Inside or outside of arch
 Surfaces toward face are facial (can use buccal if posterior, labial if anterior)
 Surfaces toward tongue are lingual (can use palatal if maxillary)
o Anatomic tooth
 If above crown of tooth, use “coronal to”
 If below apices of tooth, use “apical to”
Eruption Patterns
 3 phases of eruption: Primary, mixed, and permanent dentitions
 Primary dentition
o Starts to erupt between 6-12 months
o 1st teeth are usually lower central incisors; last teeth are 2nd molars
 Mixed dentition
o A combination of primary and permanent teeth have erupted
o 1st permanent teeth are permanent 1st molars at 6 years
o Exfoliation of primary incisors followed by eruption of permanent incisors (6-9 years)
o Exfoliation of primary mandibular Cs followed by eruption of permanent mandibular Cs (910 years)
o Exfoliation of primary Ms followed by eruption of PMs (10-12 years)
o Exfoliation of primary maxillary Cs followed by eruption of permanent Cs (11-12 years)
 May get crowded out of arch, either impacted or malerupted
 High incidence of dentigerous cyst formation with impaction of these teeth
 Permanent dentition
o No more primary teeth in jaws
o Eruption of permanent 2nd Ms (11-13 years)

o Eruption of 3rd Ms (17-21 years)
 Impactions are common; dentigerous cysts may occur around crown of impacted
tooth
Tooth Anatomy
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Diagnostic Imaging Oral and Maxillofacial


Teeth are made up of 4 basic anatomic structures: Enamel, dentin, cementum, and pulp
o Enamel
 Hardest substance in body = most mineralized (95% calcified) = highest
radiographic density
 Covers crown of tooth; contacts dentin at dentinoenamel junction (DEJ)
 Contacts cementum at cementoenamel junction (CEJ)
 Develops from ameloblasts
o Dentin
 Makes up majority of tooth; provides resiliency to hard overlying enamel; 75%
calcified
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

Contains dentinoblastic processes: Tooth becomes sensitive when dentin is
exposed
o Cementum
 Thin layer of calcified material covering root of tooth and providing attachment for
periodontal ligament (PDL)
 Not visible radiographically unless hypercementosis occurs

o Pulp (a.k.a. “nerve”)
 Vital portion of tooth (tooth “dies” when pulp dies)
 Contains nerves and vessels that enter and emerge through apical foramen of
tooth
 Most radiolucent portion of tooth
 Crown portion called “pulp chamber” with pointy “pulp horns”; root portion called
“pulp canal”
 Teeth are made up of crown and root
o Crown: Everything above CEJ
 Further subdivided into occlusal/incisal, middle, and cervical thirds
 Incisors have incisal edges as functional component; all other teeth have cusps
o Root: Everything below CEJ
 Further subdivided into cervical, middle, and apical thirds
 Teeth can have single root or be multirooted; area between roots of tooth is called
“furcation area”
 Roots are named according to location in alveolar process: Buccal, lingual, mesial,
distal, mesiobuccal, distobuccal
Periodontium
 Primary function is to support teeth; when teeth are lost, periodontal bone recedes
 Made up of periodontal bone, periodontal ligaments, and gingiva
o Periodontal bone
 Portion of alveolar processes of maxilla and mandible that come in direct contact
with teeth
 Most cervical aspect called “crest”; corticated when healthy
 If tooth is lost, most cervical aspect of bone is called “residual ridge”
 Bone at apex of tooth called “periapical bone”
 Bone in furcation area called “furcal bone”
 Thin radiopaque line seen radiographically lining tooth socket is called “lamina
dura”
o Periodontal ligament (PDL)

 Multidirectional fibers that attach tooth to socket; offer resilience to tooth during
function
 Radiographically seen as uniform radiolucent line on inside of lamina dura
 If loses uniformity, suspect pathology
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Diagnostic Imaging Oral and Maxillofacial


Houses epithelial rests of Malassez, which may contribute to formation of cyst
lining for odontogenic cysts
 Position in relation to tooth can determine if lesion is attached to tooth structure
(inside PDL) or not (outside PDL)
o Gingiva (a.k.a. “gums”)
 Soft tissue component covering periodontal bone
 Attaches to root to form small gingival sulcus with crown; cannot be visualized
radiographically
Tooth Development and Tumorigenesis
 Potential sources for development of tumors
o Pre-functional dental lamina (odontogenic epithelium with ability to produce tooth); more
abundant distal to lower 3rd molars
o Post-functional dental lamina: Epithelial remnants such as rests of Serres in fibrous gingival
tissue; epithelial cell rests of Malassez in PDL and reduced enamel organ epithelium (covers
the enamel surface until tooth eruption)
o Basal cell layer of gingival epithelium (source of dental lamina)
o Dental papilla (origin of dental pulp); can be induced to produce odontoblasts and
synthesize dentin &/or dentinoid material
o Dental follicle
o Periodontal ligament: Can induce production of fibrous and cemento-osseous mineralized

material
ANATOMY IMAGING ISSUES
Imaging Recommendations
 For imaging of teeth for caries, periapical or periodontal disease, intraoral radiography is
recommended
o Horizontal bitewings for caries and early periodontal disease detection
o Vertical bitewings for moderate to severe periodontal disease
o Periapical radiographs if periapical pathology is suspected
o Pros: High-resolution images showing fine changes in demineralization; low radiation dose,
especially if F-speed film or digital radiography is used
o Cons: Limited to dimensions of intraoral film, cannot see lesions or impacted teeth if they
extend beyond
 For general overview of teeth in jaws: Panoramic radiography
o Shows eruption pattern and impactions of teeth; presence of intraosseous pathology
o Pros: Cost effective; lower radiation dose when compared to CBCT
o Cons: Distortion, magnification and blurring can impede evaluation
 For relationship of impacted teeth with vital anatomic structures: CBCT
o Can show inferior alveolar nerve (IAN) canals in relation to 3rd molars if extraction is
planned
o Can show relationship of impacted canines to anterior superior alveolar canal, nasopalatine
canal, and floor of nasal cavity
o Pros: 3D representation of 3-dimensional structures; 3D reformations can be obtained to
give exact visualization of anatomy
o Cons: Expensive imaging modality, generally not covered by insurance; higher radiation
dose
o If unable to obtain CBCT or CT, use intraoral radiography and “SLOB” (same lingual,
opposite buccal) rule and 2 images at right angles to one another
P.I(1):4

Image Gallery

TOOTH DEVELOPMENT

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Diagnostic Imaging Oral and Maxillofacial

(Top) Graphic shows stages of tooth development: (A) Initiation: Ectoderm develops oral epithelium and
dental lamina, (B) Bud stage: Dental lamina grows into bud penetrating the ectomesenchyme, (C) Cap
stage: Enamel organ forms cap surrounding dental papilla and surrounded by dental sac, (D) Bell stage:
Differentiation of enamel organ and dental papilla into different cells types, (E) Apposition stage: Secretion
of dental tissue matrix, and (F) Maturation: Full mineralization of dental tissues. (Bottom) Graphic shows
stages of root development: (A) apposition stage, (B) enamel deposition completion at the cervical loop
and formation of Hertwig epithelial root sheath from inner and outer enamel epithelium cells, (C) root
sheath disintegration and fragmentation of some of its cells into epithelial rests of Malassez, and (D)
formation of cementum and periodontal ligaments with persistence of these epithelial remnants, which
may be the source of the epithelial component of some odontogenic cysts and tumors.
P.I(1):5

TOOTH ERUPTION

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Diagnostic Imaging Oral and Maxillofacial

(Top) Graphic shows process of tooth eruption: (A) enamel organ reduces to thin layers covering enamel
and secretes enzymes, (B) fusion of the reduced enamel epithelium with the oral epithelium, (C)
disintegration of the central fused tissues, leaving a canal for tooth movement, and (D) peripheral fused
tissues peel back from the crown as the tooth erupts and form initial junctional epithelium that migrate

cervically to cementoenamel junction. (Bottom) The age of the patient can be determined by examining the
eruption of the teeth. This CBCT 3D reformation shows that the permanent incisors and 1st molars have
erupted, but the premolars have not. This puts the patient's age at between 8-10 years. 3D reformations
can be helpful in evaluation of erupting teeth if malocclusion and malalignment are present. Note that the
maxillary right central incisor has not fully erupted although the apical foramen is almost closed. This may
be due to ankylosis (loss of PDL) of the tooth. (Courtesy 3D Diagnostix, Inc.)
P.I(1):6

TEETH NOMENCLATURE AND ERUPTION AGES

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Diagnostic Imaging Oral and Maxillofacial

(Top) The maxilla has 16 permanent teeth arranged in 2 quadrants: the upper right (UR) quadrant, also
known as quadrant 1, and the upper left (UL) quadrant, also known as quadrant 2. Eruption ages are in
parenthesis. The functional cusps on the maxillary posterior teeth are lingual (palatal) cusps. (Bottom) The
mandible has 16 permanent teeth arranged in 2 quadrants: the lower left (LL) quadrant, also known as
quadrant 3, and the lower right (LR) quadrant, also known as quadrant 4. Eruption ages are noted in
parentheses. The functional cusps on the mandibular posterior teeth are the buccal (facial) cusps. The
permanent maxillary and mandibular incisors and canines have similarly named deciduous predecessors.
The predecessors of the 1st and 2nd premolar teeth are the 1st and 2nd deciduous molars respectively.
The deciduous incisors and canines have a single root, the mandibular deciduous molars have 2 roots, and
the maxillary deciduous molars have 3 roots.
P.I(1):7

HUMAN DENTITIONS

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Diagnostic Imaging Oral and Maxillofacial

(Top) Panoramic reformat of CBCT data shows a patient at the primary dentition stage. All 20 primary teeth
have erupted into the oral cavity and are in occlusion, but all permanent teeth are still unerupted.
Examination of the follicles of the permanent teeth for any displacement or expansion is recommended
when evaluating images for the primary dentition phase. It is also important to note any missing
permanent teeth to aid in future orthodontic treatment planning. (Middle) Panoramic radiograph shows a
patient at the mixed dentition stage. The upper and lower permanent 1st molars have erupted, as well as
the upper and lower incisors. As the premolars have not erupted yet, it means the patient's age is between
8 and 10 years. (Bottom) CBCT panoramic reformat shows a patient in the permanent dentition stage. All
erupted teeth are permanent. The developing 3rd molars are present but unerupted. The stage of 3rd
molar development indicates that the patient is between 17 and 20 years of age.
P.I(1):8

DENTAL ANATOMY

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Diagnostic Imaging Oral and Maxillofacial

(Top) Graphic representation shows a mandibular 1st molar in cross section through the mesial root.
Identification of the location of pathology in relation to the DEJ and CEJ helps in classifying caries and
periodontal disease. Mandibular posterior teeth are tilted slightly lingually to fit the opposing teeth
following the curve of Wilson. Cross sections of the teeth are the most common reformation for dental
applications, such as implant and impaction analysis, as they allow for evaluation of alveolar bone width
and height and accurate localization of the IAN canal. (Bottom) Graphic representation shows sagittal cross
section of a mandibular 1st molar. The tooth is attached to the socket through the periodontal ligaments.

The crest of the healthy alveolar bone is located about 1-2 mm apical to the CEJ of a tooth. Innervation and
vasculature exit through the apical foramen, but on occasion lateral canals may exit through the lateral
aspects of the root. If pulpal death occurs, bacteria can seep through the lateral canals, causing lateral
radicular abscesses and cysts, and through the apical foramina, causing periapical inflammation.
P.I(1):9

DENTAL RADIOGRAPHIC ANATOMY

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Diagnostic Imaging Oral and Maxillofacial

(Top) Periapical radiograph shows normal dental and periodontal anatomy. The periodontal ligament (PDL)
space is a thin radiolucent line that surrounds the root of the tooth. The lamina dura is a thin radiopaque
line that surrounds the tooth socket radiographically. Healthy alveolar bone crests (crestal laminae dura)
are corticated. Nutrient canals may appear as small corticated canals within the bone connected to the
apical foramen. (Courtesy M. Kroona, DXT.) (Bottom) Periapical radiograph of the central incisors shows the
normal anatomic landmarks in this area. It is important to realize that soft and hard tissue superimpositions
may occur when imaging teeth, and their recognition is necessary to determine normal from abnormal.
Evaluation of the interproximal contact point and crown contours is important as caries tends to occur
cervical to the contact point, and incomplete contact or improper crown contour may lead to plaque
accumulation and resulting caries and periodontal disease. (Courtesy M. Kroona, DXT.)
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TOOTH IMPACTIONS

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Diagnostic Imaging Oral and Maxillofacial

(Top) Cross sections and panoramic and 3D reformations using Simplant® software show the IAN canal
traveling between the roots of the distoangularly impacted mandibular left 3rd molar. (Courtesy 3D
Diagnostix, Inc.) (Middle) Panoramic and 3D reformations show a horizontally impacted left 3rd molar with
its crown oriented distally and an impacted supernumerary tooth (4th molar) with its crown oriented
mesially, both lying on top of the left IAN canal. The right 3rd molar is horizontally impacted with its crown
oriented mesially. CBCT imaging can aid in predicting and preventing nerve damage when removing 3rd
molars surgically. (Courtesy 3D Diagnostix, Inc.) (Bottom) 3D reformation shows the left IAN going through
the mesial root of the mesioangularly impacted mandibular left 3rd molar. This occurs during tooth
development due to proximity of the tooth follicle to the IAN, which is engulfed in the root as it develops
and calcifies. (Courtesy 3D Diagnostix, Inc.)
P.I(1):11

TOOTH IMPACTIONS

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Diagnostic Imaging Oral and Maxillofacial

(Top) CBCT 3D reformation with transparent bone shows the vertical impaction of the permanent canines
with lingual placement of the crowns and slight facial tipping of the roots. Knowledge of this orientation
aids the surgeon in deciding on the entry point for either extraction or exposure of the crowns for
placement of an orthodontic bracket. (Courtesy 3D Diagnostix, Inc). (Middle) The bone can also be
“removed” on CBCT 3D reformations to further visualize the relationship of the teeth with one another.
This image shows unerupted maxillary canines with the crowns oriented facially. The roots are not
completely formed. (Courtesy 3D Diagnostix, Inc.) (Bottom) CBCT 3D reformation using Simplant® software
shows an impacted mandibular canine. The position of the impacted tooth in relation to the erupted
dentition can easily be determined with 3D reformation. Virtual extractions (digital removal of teeth) can

also be performed. (Courtesy 3D Diagnostix, Inc.)

2. Dental Restorations
TERMINOLOGY
Definitions
 Materials used to restore form and function of teeth or to enhance dental esthetics
IMAGING ANATOMY
Restorative Materials
 Amalgam
o Traditional “silver” filling material
o Combination of silver, mercury, tin, and copper and sometimes zinc, indium, and palladium
o Metallic in density
 Composite
o Tooth-colored restoration
24