PART III Interpretation

C H A P T E R

Principles of Radiographic
Interpretation
Mariam Baghdady
17
OUTLINE
Adequate Diagnostic Images Step 3: Analyze Internal Structure Clinical Information
Visual Search Strategies Step 4: Analyze Effects of Lesion on Surrounding Findings
Diagnostic Reasoning in Oral Radiology Structures Interpretation
Analysis of Abnormal Findings Step 5: Formulate Interpretation Self-Test
Analytic or Systematic Strategy Writing a Diagnostic Imaging Report Description
Step 1: Localize Abnormality Patient and General Information
Step 2: Assess Periphery and Shape Imaging Procedure

D
entists are expected to have basic skills in interpreting any the employment of a systematic search strategy by novice clini-
intraoral or extraoral images that might be used in dental cians improves their ability to detect abnormalities in panoramic
practice. This ability requires the mastery of two identifi- images. A systematic search strategy involves the identification of
able and nonseparable components of visual diagnosis: perception, a list of normal anatomic structures that would be contained
the ability to recognize abnormal patterns in the image, and cogni- within the image. In a panoramic image, this strategy might involve
tion, the interpretation of these abnormal patterns to arrive at a identifying the posterior border of the maxilla, the floor of the
diagnosis. This chapter provides an overview of diagnostic reason- sinus, the zygomatic process of the maxilla, and the orbital rim.
ing in oral radiology. It also provides an analytic framework to aid In a periapical image, the list might include crown, root structure,
in the interpretation of diagnostic images. This framework will pulp and pulp canal, periodontal membrane space, and lamina
equip the reader with a systematic method of image analysis. dura. In a data set of cone-beam computed tomographic (CBCT)
images, the normal anatomy would be inspected through the
whole image volume using axial, coronal, and sagittal image slices.
ADEQUATE DIAGNOSTIC IMAGES When faced with a complex appearance of anatomic structures,
Any method of image analysis is limited by the information con- having a systematic search strategy enables the novice clinician
tained in the available diagnostic images. Ensuring that there are to search the complete image in a meaningful and more successful
an adequate number of images of diagnostic quality that display fashion. When an abnormality has been detected in an image,
the region of interest in its entirety is an essential first step. When the clinician must focus on formulating an interpretation of the
using plain or projection images, multiple images at slightly differ- abnormality.
ent projection angles and images exposed at right angles to one
another often provide significant additional information. When
appropriate, the use of advanced forms of diagnostic imaging can
DIAGNOSTIC REASONING IN ORAL RADIOLOGY
also provide valuable diagnostic information (see Chapter 16). Clinical reasoning in diagnostic oral radiology can be considered
unique in that the initial task requires the clinician to engage in a
complex perceptual phase that involves differentiating normal and
VISUAL SEARCH STRATEGIES abnormal anatomic structures on two-dimensional images that
The ability to find and identify abnormal patterns in the diagnostic represent three-dimensional structures. After the search process, if
image first involves a visual search of the entire image. An ability a finding is deemed abnormal, the clinician forms a mental three-
to recognize an abnormal pattern requires an in-depth knowledge dimensional image of the abnormality that includes the precise
of the variations of appearances of normal anatomy. This is espe- location, size, internal structure, and how the abnormality affects
cially true in searching panoramic images. It is likely that expe- the surrounding normal structures. This complex perceptual step
rienced radiologists use a free search pattern when analyzing a is a method of identifying features of the abnormality used to
diagnostic image. However, more recent research has shown that arrive at a plausible diagnosis.

271
272 P A RT I I I Interpretation

A common method for a novice clinician is to memorize spe- The second form, a nonanalytic strategy, assumes that simply
cific features of each type of abnormality and then attempt to use viewing an abnormal finding automatically leads to a holistic
this information to interpret images. This approach has been diagnostic hypothesis, which is followed by a deliberate search for
shown to be ineffective in correct interpretation of radiographic features that support the initial hypothesis. The nonanalytic
abnormalities. However, it has been found that understanding the approach suggests that the clinician makes an automatic decision
basic disease mechanism underlying the changes that each type of regarding the diagnosis without thorough feature analysis of the
abnormality can render in the diagnostic image is more effective image. For example, expert radiologists may rely on pattern recog-
in enhancing a clinician’s diagnostic accuracy. The terms “disease nition as a nonanalytic diagnostic strategy.
mechanism” and “basic science” are used to represent the patho- There is some empirical evidence that nonanalytic reasoning
physiologic basis of abnormalities at the cellular, tissue, and bio- can be successfully employed by novice clinicians. However, critics
chemical levels. More recent research suggests that the understanding of teaching novices to rely on nonanalytic processing argue that
of disease mechanisms plays an essential role in enhancing diag- the success of this diagnostic strategy is limited by the novice’s
nostic accuracy in novice clinicians. Basic science knowledge minimal experience and the varied appearances of both normal
apparently creates a coherent mental representation of diagnostic anatomy and pathologic disorders in images.
categories and their features. According to this theory, basic sci- Although these two processes are viewed as separate mecha-
ences may assist in “true understanding” of the diagnostic entities nisms, research provides evidence that they are complementary
by creating coherent mental representations of different disease and should not be viewed as being mutually exclusive. Students
categories. Hence, when clinicians understand why certain features learning oral radiology could potentially benefit from specific
occur, they are able to make the diagnosis that “makes sense,” training in the use of combined analytic and nonanalytic diagnos-
rather than simply focusing on feature counting and rote memory. tic strategies.
Also, more recent research shows that teaching disease mechanisms An analytic tool for the analysis of abnormal findings is pre-
and radiographic features in an integrated fashion produced novice sented in the next section. The main function of this tool is to
clinicians with higher diagnostic accuracy than novice clinicians collect all the available imaging characteristics of the abnormal
who were taught in a segregated manner. finding. Once the information is assembled, it is useful in the
Worth, a pioneer in diagnostic oral radiology, stated, “Radio- diagnostic process.
graphic appearances are governed by anatomic and physiologic As the imaging characteristics are being collected, it is impor-
changes in the presence of disease processes. Radiologic diagnosis tant to integrate the disease mechanism underlying these charac-
is founded on knowledge of these alterations, the prerequisite teristics when possible. For instance, Figure 17-2 depicts the
being awareness of disease mechanisms.” maturation of periapical osseous dysplasia (periapical cemental
dysplasia). At the first stage (Fig. 17-2, A), the periapical bone is
resorbed and replaced with fibrous tissue, and therefore it appears
ANALYSIS OF ABNORMAL FINDINGS radiolucent in the image. In a later maturation stage, this abnor-
There are two main forms of diagnostic processing described in mality produces amorphous bone in the center (Fig. 17-2, B),
radiology; the first is the analytic or systematic strategy. This resulting in a radiopaque mass in the center surrounded by a soft
approach relies on a step-by-step analysis of all the imaging features tissue radiolucent rim. Knowledge of the disease mechanism allows
of an abnormal finding so that a diagnosis can be made based on for the correct diagnosis of a lesion of periapical osseous dysplasia
these findings (Fig. 17-1). This analytic process is believed to reduce in an unusual location in the maxilla and after the associated tooth
bias and premature closure of the decision-making process. has been extracted (Fig. 17-2, C).

Learning disease categories

Radiographic features and
causal connections using
Learning disease mechanisms
strategy

Radiographic case

Analytical strategy Non-analytical strategy

FIGURE 17-1 Diagram illustrating the diagnostic process in oral radiology.
The learning strategy phase represents the stage at which a novice learns about
disease categories. The diagnostic strategy phase demonstrates the diagnostic Features
techniques used by the clinician when faced with an abnormality. Location Internal structure
Diagnostic Size and shape Effect on surrounding
strategy Borders structures

Normal or abnormal?
Reconciliation of
Acquired or developmental?
diagnosis with features
Classification of disease?

Final interpretation
 C H AP TER 17 Principles of Radiographic Interpretation 273

A B

FIGURE 17-2 Series of periapical images showing different maturation phases of periapical osseous dysplasia. A, Early radiolucent
phase after periapical bone has been resorbed and replaced with fibrous tissue (arrows). B, Late maturation phase showing central
amorphous bone (radiopaque) surrounded by a soft tissue margin (arrows). C, Mature phase of periapical osseous dysplasia in an unusual
location and after the associated tooth has been extracted.

This is not to say that localized pathologic lesions cannot occur

ANALYTIC OR SYSTEMATIC STRATEGY bilaterally in the maxillofacial region. A few abnormalities, such as
Paget’s disease and cherubism, are always seen bilaterally in the
STEP 1: LOCALIZE ABNORMALITY jaws. Also, when cherubism involves the mandible, the first region
Localized or Generalized to be involved is in the midramus region, and this is the mecha-
The anatomic location and limits of the abnormality should be nism behind the anterior displacement of molars (Fig. 17-3).
described. This information aids in starting to select various disease
categories. If an abnormal appearance affects all the osseous struc- Position in the Jaws
tures of the maxillofacial region, generalized disease mechanisms, Identifying the exact location of the lesion in the maxillofacial
such as metabolic or endocrine abnormalities of bone, are consid- complex aids the diagnostic process in two ways: (1) it determines
ered. If the abnormality is localized, one considers whether it is the epicenter and (2) some lesions tend to be found in specific
unilateral or bilateral. Variations of normal anatomy are more locations.
commonly bilateral. For instance, a bilateral mandibular radiolu- Determining the epicenter of the lesion or the point of origin
cency may indicate normal anatomy, such as extensive subman- assists in indicating the tissue types that compose the abnormality
dibular gland fossa. Abnormal conditions are more commonly in question. The epicenter can be estimated on the basis of the
unilateral. For instance, fibrous dysplasia commonly is unilateral. assumption that the abnormality grew equally in every direction.
274 P A RT I I I Interpretation

This estimation may become less accurate with very large lesions • The probability of cartilaginous lesions and osteochondromas
or lesions with ill-defined boundaries. Following are a few exam- occurring is greater in the condylar region.
ples of relating the epicenter of the lesion to the tissue of origin: • If the epicenter is within the maxillary antrum, the lesion is
• If the epicenter is coronal to a tooth, the lesion probably is not of odontogenic tissue, as opposed to a lesion that has
composed of odontogenic epithelium (Fig. 17-4). grown into the antrum from the alveolar process of the maxilla
• If it is above the inferior alveolar nerve canal (IAC), the (Fig. 17-8).
likelihood is greater that it is composed of odontogenic tissue The other reason to establish the exact location of the lesion is
(Fig. 17-5). that particular abnormalities tend to be found in very specific
• If the epicenter is below the IAC, it is unlikely to be odonto- locations. Following are a few examples of this observation:
genic in origin (Fig. 17-6). • The epicenters of central giant cell granulomas commonly are
• If it originates within the IAC, the tissue of origin probably is located anterior to the first molars in the mandible and anterior
neural or vascular in nature (Fig. 17-7). to the cuspid in the maxilla in young patients.

FIGURE 17-3 This lesion, cherubism, is bilat-

eral, manifesting in both the left and the right man-
dibular rami. Because the origin of the lesion is in the
midramus region, the mandibular molars have been
displaced anteriorly on both sides.

A B

FIGURE 17-4 A, Cropped panoramic image of a lesion where the epicenter is coronal to the unerupted mandibular first molar.
B, Occlusal projection providing a right-angle view of the same lesion.
 C H AP TER 17 Principles of Radiographic Interpretation 275

FIGURE 17-5 Panoramic image revealing a

cystic ameloblastoma within the body of the left man-
dible. The inferior alveolar nerve canal has been dis-
placed inferiorly to the inferior cortex (arrows),
indicating that the lesion started superior to the canal.

FIGURE 17-8 The lack of a peripheral cortex (arrows) on this retention pseudocyst
FIGURE 17-6 Cropped panoramic image displaying a lesion (developmental salivary indicates that it originated in the sinus and not in the alveolar process. Therefore, it is unlikely
gland defect) below the inferior alveolar canal and thus unlikely to be of odontogenic origin. to be of odontogenic origin.

• Osteomyelitis occurs in the mandible and rarely in the maxilla.

• Periapical osseous dysplasia (periapical cemental dysplasia)
occurs in the periapical region of teeth (see Fig. 17-2).

Single or Multifocal
Establishing whether an abnormality is solitary or multifocal aids
in understanding the disease mechanism of the abnormality. Addi-
tionally, the list of possible multifocal abnormalities in the jaws is
relatively short. Examples of lesions that can be multifocal in the
jaws are periapical cemental dysplasia, keratocystic odontogenic
tumors, metastatic lesions, multiple myeloma (Fig. 17-9), and leu-
kemic infiltrates. Exceptions to all these points may occur occa-
sionally. However, these criteria may serve as a guide to an accurate
interpretation.

Size
FIGURE 17-7 Lateral oblique view of the mandible revealing a lesion within the inferior Finally, the size of the lesion is considered. There are very few size
alveolar canal. The smooth fusiform expansion of the canal indicates a neural lesion. restrictions for a particular lesion, but the size may aid in the
276 P A RT I I I Interpretation

FIGURE 17-11 Cropped panoramic image showing the poorly defined border of a
malignant neoplasm that has destroyed bone between the first molar and the first bicuspid.

ill-defined periphery (Fig. 17-11). The periphery can also have a

FIGURE 17-9 Cropped panoramic film revealing several small, punched-out lesions of dimension or a zone of transition. For instance, a thin radiopaque
multiple myeloma (a few are indicated by arrows) involving the body and ramus of the line or cortex at the periphery would represent a narrow zone of
mandible. transition, as opposed to a thick sclerotic border, which would
represent a relatively thick zone of transition. Further analysis of
these two types of peripheries or borders can help define the nature
of the lesion.

Well-Defined Borders
Punched-Out Border. A punched-out border is one that has a sharp
boundary or a very narrow zone of transition in which no bone
reaction is apparent immediately adjacent to the abnormality; this
is analogous to punching a hole in a radiograph with a paper
punch. The border of the resulting hole is well defined, and the
surrounding bone has a normal appearance up to the edge of the
hole. This type of border sometimes is seen in multiple myeloma
(see Fig. 17-9).

Corticated Border. A corticated margin is a thin, fairly uniform

radiopaque line of reactive bone at the periphery of a lesion. This
is commonly seen with cysts and benign slow-growing tumors (see
Fig. 17-4).
FIGURE 17-10 Lateral oblique projection of the mandible showing the well-defined
border (arrows) of a residual cyst.
Sclerotic Margin. A sclerotic margin represents a wider zone of
transition made up of a thick radiopaque border of reactive bone
that usually is not uniform in width. This margin may be seen with
differential diagnosis. For instance, when differentiating between a periapical osseous dysplasia and may indicate a very slow rate of
dentigerous cyst and a hyperplastic follicle surrounding the coronal growth or the potential for the lesion to stimulate the production
portion of a tooth, size may be considered a determining factor. of surrounding bone (see Fig. 17-2).
Because dentigerous cysts have growth potential, they are often
much larger than a hyperplastic follicle. Soft Tissue Capsule. A radiopaque lesion may have a soft tissue
capsule, which is indicated by the presence of a radiolucent line
STEP 2: ASSESS PERIPHERY AND SHAPE at the periphery. This soft tissue capsule may be seen in conjunc-
One should study the periphery of the lesion. Is the periphery well tion with a corticated periphery, as is observed with odontomas
defined or ill defined? If an imaginary pencil can be used to draw and cementoblastomas (Figs. 17-12 and 17-13).
confidently the limits of the lesion, the margin is well defined (Fig.
17-10). The clinician should not become concerned if some small Ill-Defined Borders
regions are ill defined; these may be due to the shape or direction Blending Border. A blending border is a gradual, often wide zone
of the x-ray beam at that particular location. A well-defined lesion of transition between the adjacent normal bone trabeculae and the
is one in which most of the periphery is well defined. In contrast, abnormal-appearing trabeculae of the lesion. The focus of this
it is difficult to draw an exact delineation around most of an observation is on the trabeculae and not on the radiolucent marrow
 C H AP TER 17 Principles of Radiographic Interpretation 277

FIGURE 17-14 Periapical image shows a gradual transition from the dense trabeculae
of sclerosing osteitis (short arrow) to the normal trabecular pattern near the crest of the alveolar
process (long arrow). This is an example of an ill-defined, blending border.

around existing trabeculae, producing radiolucent, finger-like, or

bay-type extensions at the periphery. This growth may result in
FIGURE 17-12 Thin, radiolucent periphery indicating a soft tissue capsule positioned enlargement of the marrow spaces at the periphery (Fig. 17-16).
between the internal radiopaque structure of this odontoma and the radiopaque outer cortical Invasive borders are usually associated with rapid growth and can
boundary (arrows). be seen with malignant lesions.

Shape
The lesion may have a particular shape, or it may be irregular. Two
examples follow:
• A circular or fluid-filled shape, similar to an inflated balloon,
is characteristic of a cyst. It can also be described as hydraulic
(see Fig. 17-4).
• A scalloped shape is a series of contiguous arcs or semicircles
that may reflect the mechanism of growth (Fig. 17-17). This
shape may be seen in cysts (e.g., keratocystic odontogenic
tumors), cystlike lesions (e.g., simple bone cysts), and some
tumors. Occasionally, a lesion with a scalloped periphery is
referred to as multilocular; however, the term multilocular is
reserved for the description of the internal structure in this text.

STEP 3: ANALYZE INTERNAL STRUCTURE

The internal appearance of a lesion can be classified into one of
three basic categories: totally radiolucent, totally radiopaque, or
mixed radiolucent and radiopaque (mixed density). A totally
radiolucent interior is common in cysts (see Fig. 17-4, A), and a
FIGURE 17-13 Periapical image revealing a radiopaque mass associated with the root
totally radiopaque interior is observed in osteomas. The mixed
of the first bicuspid. The prominent radiolucent periphery (arrows) is characteristic of a soft
density internal structure is seen as the presence of calcified struc-
tissue capsule of this benign cementoblastoma.
tures (white) against a radiolucent (black) backdrop. A challenging
aspect of this analysis may be the decision concerning whether a
perceived calcified structure is in the internal aspect of the lesion
spaces. Examples of conditions with this type of margin are scleros- or resides on either side of it; this is difficult to determine by using
ing osteitis (Fig. 17-14) and fibrous dysplasia. two-dimensional images representing three-dimensional structures.
The shape, size, pattern, and density of the calcified structure
Invasive Border. An ill-defined invasive border appears as an area should be examined. For example, bone can be identified by the
of radiolucency with few or no trabeculae representing bone presence of trabeculae. Also, the degree of radiopacity may help.
destruction just behind and at the leading margin of the lesion and For instance, enamel is more radiopaque than bone. Following is
usually has a wide zone of transition (Fig. 17-15). In contrast to a list of most radiolucent to most radiopaque material seen in plain
the blending border, the focus of this observation is on the enlarg- radiographs:
ing radiolucency at the expense of bone trabeculae. These borders • Air, fat, and gas
have also been described as permeative because the lesion grows • Fluid
278 P A RT I I I Interpretation

A B

FIGURE 17-15 Periapical (A) and occlusal (B) images revealing a squamous cell carcinoma in the anterior maxilla. The invasive
margin extends beyond the lateral incisor (arrow), and the radiolucent region with no apparent trabeculae represents bone destruction
behind this margin.

FIGURE 17-16 Lateral occlusal view of a lesion revealing an ill-defined periphery with
enlargement of the small marrow spaces at the margin (arrow). This is characteristic of a
malignant neoplasm, in this case a lymphoma. FIGURE 17-17 Cropped panoramic image of an odontogenic keratocyst displaying a
scalloped border, especially around the apex of the associated teeth (arrows).

• Soft tissue
• Bone marrow
Abnormal Trabecular Patterns
• Trabecular bone Abnormal bone may have various trabecular patterns different
• Cortical bone and dentin from normal bone. These variations result from a difference in the
• Enamel number, length, width, and orientation of the trabeculae. For
• Metal instance, in fibrous dysplasia, the trabeculae usually are greater in
This list is useful, but the amount of the tissue or material in number, shorter, and not aligned in response to applied stress to
the area can affect the degree of radiolucency or radiopacity. For the bone but are randomly oriented, resulting in patterns described
example, a large amount of cortical bone may be as radiopaque as as an orange-peel or a ground-glass appearance (Fig. 17-18). Another
enamel. example is the stimulation of new bone formation on existing
The following section describes possible internal structures that trabeculae in response to inflammation. The result is thick trabecu-
may be seen in mixed density lesions lae, giving the area a more radiopaque appearance (see Fig. 17-14).
 C H AP TER 17 Principles of Radiographic Interpretation 279

Amorphous Bone
This type of dystrophic bone has a homogeneous, dense, amor-
phous structure and sometimes is organized into round or oval
shapes (see Fig. 17-2).

Tooth Structure
Tooth structure usually can be identified by the organization into
enamel, dentin, and pulp chambers. Also, the internal density is
equivalent to the density of tooth structure and greater than the
density of the surrounding bone (see Fig. 17-12).

STEP 4: ANALYZE EFFECTS OF LESION ON

SURROUNDING STRUCTURES
Evaluating the effects of the lesion on surrounding structures
allows the observer to infer its behavior. The behavior may aid in
identification of the disease. However, knowledge of the mecha-
nisms of various diseases is required. For instance, inflammatory
disease, as is seen in periapical osteitis, can stimulate bone resorp-
tion or formation. Bone formation may occur on the surface of
existing trabeculae, resulting in thick trabeculae, which is reflected
in the trabecular pattern and in an overall increase in the radiopac-
ity of the bone (see Fig. 17-14). A space-occupying lesion, such as
a cyst, slowly creates its own space by displacing teeth and other
FIGURE 17-18 Periapical image of a small lesion of fibrous dysplasia between the lateral surrounding structures (see Fig. 17-4). The following sections give
incisor and cuspid demonstrates a change in bone pattern. A greater number of trabeculae per examples of effects on surrounding structures and the conclusions
unit area are present, and the trabeculae are small and thin and randomly oriented in an that may be inferred from the behavior of the lesions.
orange-peel pattern.
Teeth, Lamina Dura, and Periodontal Membrane Space
Displacement of teeth is seen more commonly with slower growing,
space-occupying lesions. The direction of tooth displacement is
significant. Lesions with an epicenter above the crown of a tooth
Internal Septation (i.e., follicular cysts and occasionally odontomas) displace the
Septations within a lesion represent bone that has been organized tooth apically (see Fig. 17-4, A). Because cherubism originates and
into long strands or walls within the lesion. If these septa appear grows in the mandibular ramus, it has a propensity to push molars
to divide the internal structure into at least two compartments, the in an anterior direction (see Fig. 17-3). Some lesions (e.g., lym-
term multilocular is used to describe the lesion. The origin of this phoma, leukemia, Langerhans’ cell histiocytosis) grow in the
internal bone may be trapped bone, such as in ameloblastomas, papilla of developing teeth and may push the developing tooth in
or reactive bone, such as in giant cell granulomas, or the bone may a coronal direction (Fig. 17-20).
be manufactured by the lesion, such as in ossifying fibromas. The Resorption of teeth usually occurs with a more chronic or
length, width, and orientation of the septa should be assessed. The slowly growing process (see Fig. 17-4, A). It may also result from
appearance of the septa also informs the observer about the nature chronic inflammation. Although tooth resorption is more com-
and pathology of the lesion. For instance, curved, coarse septa may monly related to benign processes, malignant tumors occasionally
be seen in ameloblastoma giving the internal pattern a multilocu- resorb teeth.
lar, “soap bubble” appearance. This pattern reflects the cystic for- Widening of the periodontal membrane space may be seen with
mations at the histologic level within the ameloblastoma as these many different kinds of abnormalities. It is important to observe
cystic regions remodel the trapped bone into curved shapes (Fig. whether the widening is uniform or irregular and whether the
17-19, A and B). This pattern also may be observed sometimes in lamina dura is still present. For instance, orthodontic movement
odontogenic keratocysts. Another example of internal septation is of teeth results in widening of the periodontal membrane space,
seen in giant cell granulomas. These bony septa are reactive bone but the lamina dura remains intact. Malignant lesions can quickly
formation and in some cases represent poorly calcified osteoid and grow down the ligament space, resulting in an irregular widening
appear as low density and wispy or granular septations in the and destruction of the lamina dura (Fig. 17-21).
image. Odontogenic myxomas also exhibit internal septation. In
some cases, this tumor contains a few straight, thin septa. Surrounding Bone Reaction
Some abnormalities can stimulate a peripheral bone reaction. An
Dystrophic Calcification example is the peripheral cortex of a cyst or sclerotic border of
Dystrophic calcification is calcification that occurs in damaged soft periapical osseous dysplasia as described in the analysis of periph-
tissue. It is most commonly seen in calcified lymph nodes that ery. The corticated border of a cyst is not actually part of the cyst
appear as dense, cauliflower-like masses in the soft tissue. In chroni- but is a bone reaction. Identification of peripheral bone formation
cally inflamed cysts, the calcification may have a very delicate, provides a behavioral characteristic that suggests that the abnor-
particulate appearance without a recognizable pattern. mality has the ability to stimulate an osteoblastic reaction. An
280 P A RT I I I Interpretation

A B

C D

FIGURE 17-19 A, Periapical image of an ameloblastoma. The multilocular pattern created by septa (arrows) divides the internal
structure into small, soap bubble—like compartments. B, Axial CT image of an ameloblastoma has typically curved septa (arrow).
C, Cropped panoramic image of a giant cell granuloma with low-density granular septations (arrows). D, Coronal CT image of a myxoma
has typically straight septa (arrow).

inflammatory lesion, such as periapical rarefying osteitis, can stim-

ulate a sclerotic bone reaction (see Fig. 17-14); some metastatic
malignant tumors such as prostate and breast metastatic lesions
can stimulate an osteoblastic reaction.

Inferior Alveolar Nerve Canal and Mental Foramen

Changes to the inferior alveolar nerve canal can be characteristic
to specific disease processes. Superior displacement of the inferior
alveolar canal is strongly associated with fibrous dysplasia. Widen-
ing of the inferior alveolar canal with the maintenance of a cortical
boundary may indicate the presence of a benign lesion of vascular
or neural origin within the canal (see Fig. 17-7). Irregular widening
with cortical destruction may indicate the presence of a malignant
neoplasm growing down the length of the canal.

Outer Cortical Bone and Periosteal Reactions

The cortical boundaries of bone may remodel in response to the
growth of a lesion within the maxilla or mandible. A slowly
growing lesion may allow time for the outer periosteum to manu-
facture new bone so that the resulting expanded bone appears to
FIGURE 17-20 Leukemic infiltration of the mandible showing coronal displacement of have maintained an outer cortical plate (see Fig. 17-4, B). A rapidly
the developing second molar (white arrow) from the remnants of its crypt (black arrow). There growing lesion outstrips the ability of the periosteum to respond,
is a lack of a lamina dura around the apex of the first molar and widening of the periodontal and the cortical plate may be missing (Fig. 17-22). The remodeled
ligament space around the second deciduous molar. external shape of the mandible or maxilla can provide information
 C H AP TER 17 Principles of Radiographic Interpretation 281

A B

FIGURE 17-21 A and B, Periapical films revealing a malignant lymphoma that has invaded the mandible. There is irregular widen-
ing of the periodontal ligament spaces (arrows).

lesions and more rarely in tumors such as leukemia and Langer-

hans’ cell histiocytosis. Other examples of patterns of reactive
periosteal bone formation include a spiculated new bone formed
at right angles to the outer cortical plate, which is seen with meta-
static lesions of the prostate gland or in a radiating pattern of
spiculated bone seen in osteogenic sarcoma (Fig. 17-25) or a
hemangioma.

STEP 5: FORMULATE INTERPRETATION

The preceding steps enable the observer to collect all the radio-
graphic findings analytically in an organized fashion. (Box 17-1
presents the process in abbreviated form.) Now the significance of
each observation must be determined. The ability to give more
significance to some observations over others comes with experi-
ence; this is also seen in a nonanalytic approach. After an initial
FIGURE 17-22 Axial CT image of an ameloblastoma involving the left mandibular ramus diagnosis has been reached, ambiguities are resolved either by
shows significant expansion of the ramus with some periosteal bone formation (black arrow) searching for more features or by putting more weight on one
but with many regions of no periosteal bone formation (white arrows), which likely reflects a feature or the other. For instance, in the analysis of a hypothetical
fast rate of expansion by the ameloblastoma. lesion, the observations of tooth movement, tooth resorption, and
an invasive destructive border are made. The effects on the teeth
in this example may indicate a benign process; however, the inva-
on the growth pattern of the entity. For instance, a tumor such as sive border and bone destruction are more important characteris-
ossifying fibroma often has a concentric growth pattern, whereas tics and indicate a malignant process. In the analytic approach (see
a bone dysplasia such as fibrous dysplasia enlarges the bone with Fig. 17-1), all these accumulated characteristics are used to make a
a growth pattern that is along the bone without an obvious epi- diagnostic decision. A diagnostic algorithm such as shown in
center (Fig. 17-23). Figure 17-26 can aid in this decision-making process. Following
Exudate from an inflammatory lesion can lift the periosteum this algorithm, the observer makes decisions regarding which
off the surface of the cortical bone stimulating the osteoblasts of general category the entity fits into and then proceeds to smaller,
the periosteum to lay down new bone (Fig. 17-24). When this more specific categories. This is not an infallible method because
process occurs more than once, an onion-skin type of pattern can any algorithm occasionally may fail because lesions sometimes do
be seen. This pattern is most commonly seen in inflammatory not behave as expected.
282 P A RT I I I Interpretation

FIGURE 17-23 A, Occlusal image of an

ossifying fibroma. The concentric expansion of the
mandible is characteristic of a benign tumor.
B, Occlusal image of fibrous dysplasia with mild
expansion of the mandible but without an obvious
epicenter as it causes expansion along the mandible.

A B

BOX 17-1 Analysis of Intraosseous Lesions

STEP 1: LOCALIZE ABNORMALITY
• Anatomic position (epicenter)
• Localized or generalized
• Unilateral or bilateral
• Single or multifocal
STEP 2: ASSESS PERIPHERY AND SHAPE
Periphery
• Well defined
• Punched-out
• Corticated
FIGURE 17-24 Panoramic image of osteomyelitis revealing at least two layers of new • Sclerotic
bone (arrows) produced by the periosteum at the inferior aspect of the mandible. • Soft tissue capsule
• Ill defined
• Blending
• Invasive
Shape
• Circular
• Scalloped
• Irregular
STEP 3: ANALYZE INTERNAL STRUCTURE
• Totally radiolucent
• Totally radiopaque
• Mixed (describe pattern)
STEP 4: ANALYZE EFFECTS OF LESION ON
SURROUNDING STRUCTURES
• Teeth, lamina dura, periodontal membrane space
• Inferior alveolar nerve canal and mental foramen
• Maxillary antrum
• Surrounding bone density and trabecular pattern
• Outer cortical bone and periosteal reactions
FIGURE 17-25 Specimen radiograph of a resected mandible with an osteosarcoma. Note STEP 5: FORMULATE INTERPRETATION
the fine linear spicules of bone at the superior margin of the alveolar process (arrows).
 C H AP TER 17 Principles of Radiographic Interpretation 283

Image analysis
algorithm

Normal Abnormal

Acquired Developmental

Benign
Cyst
neoplasm
A B C

FIGURE 17-27 A-C, Periapical films revealing external resorption of the maxillary
Malignant
Inflammatory incisors, which is an acquired abnormality because of the presence of the wide pulp chambers
neoplasm
at the apex of the roots of the teeth.

Bone
Vascular
dysplasia interpretation to one of these disease categories; this directs the
next course of action for continued investigation, referral, and
treatment. This is a good time to bring the clinical information,
Metabolic Trauma
such as patient history and clinical signs and symptoms, into the
decision-making process. When possible, considering this informa-
FIGURE 17-26 Algorithm representing the diagnostic process that follows evaluation of tion at the end helps avoid the problem of doing an incomplete
the radiographic features of an abnormality. search of the images or trying to make the radiographic character-
istics fit a preconceived diagnosis.

Decision 4: Ways to Proceed

Decision 1: Normal or Abnormal After analyzing the images, the clinician must decide in what way
The clinician should determine whether the structure of interest is to proceed. This decision may require further imaging, treatment,
a variation of normal or represents an abnormality. This is a crucial biopsy, or observation of the abnormality (watchful waiting). For
decision because variations of normal do not require treatment or example, if the lesion fits in the malignant category, the patient
further investigation. However, as previously stated, to be profi- first should be referred to an oral and maxillofacial radiologist to
cient in the interpretation of diagnostic images, the clinician needs complete the diagnostic imaging to stage the lesion and select the
an in-depth knowledge of the various appearances of normal biopsy site and then should be referred to a surgeon for biopsy
anatomy. and treatment. Periapical osseous dysplasia may not require any
further investigation or treatment. In other cases, a period of
Decision 2: Developmental or Acquired watchful waiting, followed by reexamination in a few months, may
If the area of interest is abnormal, the next step is to decide whether be indicated if the abnormality appears benign and no clear need
the radiographic characteristics (location, periphery, shape, internal for immediate treatment exists.
structure, and effects on surrounding structures) indicate that the With advanced training or experience in diagnostic imaging,
region of interest represents a developmental abnormality or an the clinician may be able to name one specific abnormality or at
acquired change. For instance, the observation that a tooth has an least make a short list of entities from one of the divisions of
abnormally short root leads to the pertinent question, “Did the acquired abnormalities. When analyzing diagnostic images, it is
tooth develop a short root, or was the root at one time of normal advisable to create a formal report for the purposes of documenta-
length and has become shorter?” If the answer is the latter, the tion and communication with other clinicians.
process must be external root resorption—an acquired abnormality.
If the tooth merely developed a short root, the pulp canal should
not be visible to the very end of the root because of normal apexi-
WRITING A DIAGNOSTIC IMAGING REPORT
fication. In contrast, external root resorption may shorten the root, The radiographic report can be subdivided into the following
but the canal remains visible to the end of the root (Fig. 17-27). subsections.

Decision 3: Disease Classification PATIENT AND GENERAL INFORMATION

If the abnormality is acquired, the next step is to select the most This section appears at the beginning and contains the following
likely disease category of the acquired abnormality. The disease information: address of the radiology clinic; the date of the dicta-
category can be established through observing the features and tion; the referring clinician’s name and clinic or address; and the
how they reflect a particular disease mechanism. The categories patient’s name, age, sex, and any numeric identification such as a
may include cysts, benign tumors, malignant tumors, inflamma- clinic or medical registration number.
tory lesions, bone dysplasias (fibro-osseous lesions), vascular
abnormalities, metabolic diseases, or physical changes such as frac- IMAGING PROCEDURE
tures. The following chapters describe the characteristic radio- This section gives a list of the imaging procedures provided along
graphic findings based on the disease mechanisms of these with the date of the examination. An example could be the fol-
abnormalities. The analysis should strive at least to narrow the lowing: panoramic and intraoral maxillary standard occlusal
284 P A RT I I I Interpretation

images plus axial and coronal CT images of the mandible with tooth. Also, the lesion has displaced the second molar distally and
administration of contrast material made on February 20, 2012. the second premolar in an anterior direction. Apical resorption of
the distal root of the second deciduous molar has occurred. The
CLINICAL INFORMATION occlusal radiograph reveals that the buccal cortical plate has
This is an optional section that includes pertinent clinical informa- expanded in a smooth, curved shape, and a thin cortical boundary
tion regarding the patient provided by the referring clinician or still exists.
the clinician dictating the report if a clinical examination was made
before the radiologic examination. The clinical information should Analysis
remain brief and summarize the information pertaining to the Making all the observations is an important first step; the following
lesion in question. For example: mass in floor of mouth, possible is an analysis built on these observations. To accomplish this next
ranula, and patient has a history of lymphoma. step, further knowledge of pathologic conditions and a certain
amount of practice are required. The first objective is to select the
FINDINGS correct category of diseases (e.g., inflammatory, benign tumor,
This section comprises an objective detailed list of observations cyst); at this point, the clinician should try not to let all the names
made from the diagnostic images. This can follow the previously of specific diseases be overwhelming.
presented step-by-step analysis of the extent of the lesion, periph- These images reveal an abnormal appearance. The coronal
ery and shape, internal structure, and effects on surrounding struc- location of the lesion suggests that the tissue making up this
tures. This section does not include an interpretation. abnormality probably is derived from a component of the dental
follicle. The effects on the surrounding structures indicate that
INTERPRETATION this abnormality is acquired. The displacement and resorption of
This section is shorter and provides an interpretation for the pre- teeth, intact peripheral cortex, curved shape, and radiolucent inter-
ceding observations. The clinician should endeavor to provide a nal structure all indicate a slow-growing, benign, space-occupying
definitive interpretation. When this is not possible, a short list of lesion, most likely in the cyst category. Odontogenic tumors, such
conditions or a differential diagnosis (in order of likelihood) is as an ameloblastic fibroma, may be considered but are less likely
acceptable. In some situations, advice regarding additional studies, because of the shape. The most common type of cyst in a fol-
when required, and treatment may be included. Lastly, the name licular location is a dentigerous cyst. Odontogenic keratocysts
and signature of the clinician composing the report is included. occasionally are seen in this location, but the tooth resorption
and degree of expansion are not characteristic of that pathologic
condition. Therefore, the final interpretation is a follicular cyst,
SELF-TEST with odontogenic keratocyst and ameloblastic fibroma as possibili-
To practice the analytic technique presented, the reader should ties in the differential diagnosis but less likely. Treatment usually
examine Figure 17-4, A and B, and write down all observations is indicated for follicular cysts, and the patient should be referred
and the results of the diagnostic algorithm before reading the fol- for surgical consultation.
lowing section.
DESCRIPTION BIBLIOGRAPHY
Location Baghdady M, Carnahan H, Lam E, et al: The integration of basic
The abnormality is singular and unilateral, and the epicenter lies sciences and clinical sciences in oral radiology, J Dent Educ 2013
coronal to the mandibular first molar. (in press).
Baghdady M, Pharoah M, Regehr G, et al: The role of basic sciences in
Periphery and Shape diagnostic oral radiology, J Dent Educ 73:1187–1193, 2009.
Eva KW, Hatala RM, LeBlanc VR, et al: Teaching from the clinical
The lesion has a well-defined cortical boundary and a spherical or
reasoning literature: combined reasoning strategies help novice
round shape. The periphery also attaches to the cementoenamel diagnosticians overcome misleading information, Med Educ 41:
junction. 1152–1158, 2007.
Woods N: Science is fundamental: the role of biomedical knowledge in
Internal Structure clinical reasoning, Med Educ 41:1173–1177, 2007.
The internal structure is totally radiolucent. Worth HM: Principles and practice of oral radiologic interpretation, Chicago,
1972, Year Book Medical Publishers.
Effects
This lesion has displaced the first molar in an apical direction,
which reinforces the decision that the origin was coronal to this