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
intraoral or extraoral images that might be used in dental
practice. This ability requires the mastery of two identifi-
able and nonseparable components of visual diagnosis: perception,
the ability to recognize abnormal patterns in the image, and cogni-
tion, the interpretation of these abnormal patterns to arrive at a
diagnosis. This chapter provides an overview of diagnostic reason-
ing in oral radiology. It also provides an analytic framework to aid
in the interpretation of diagnostic images. This framework will
equip the reader with a systematic method of image analysis.
ADEQUATE DIAGNOSTIC IMAGES
Any method of image analysis is limited by the information con-
tained in the available diagnostic images. Ensuring that there are
an adequate number of images of diagnostic quality that display
the region of interest in its entirety is an essential first step. When
using plain or projection images, multiple images at slightly differ-
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
also provide valuable diagnostic information (see Chapter 16).
VISUAL SEARCH STRATEGIES
The ability to find and identify abnormal patterns in the diagnostic
image first involves a visual search of the entire image. An ability
to recognize an abnormal pattern requires an in-depth knowledge
of the variations of appearances of normal anatomy. This is espe-
cially true in searching panoramic images. It is likely that expe-
rienced radiologists use a free search pattern when analyzing a
diagnostic image. However, more recent research has shown that
the employment of a systematic search strategy by novice clini-
cians improves their ability to detect abnormalities in panoramic
images. A systematic search strategy involves the identification of
a list of normal anatomic structures that would be contained
within the image. In a panoramic image, this strategy might involve
identifying the posterior border of the maxilla, the floor of the
sinus, the zygomatic process of the maxilla, and the orbital rim.
In a periapical image, the list might include crown, root structure,
pulp and pulp canal, periodontal membrane space, and lamina
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.
When faced with a complex appearance of anatomic structures,
having a systematic search strategy enables the novice clinician
to search the complete image in a meaningful and more successful
fashion. When an abnormality has been detected in an image,
the clinician must focus on formulating an interpretation of the
abnormality.
DIAGNOSTIC REASONING IN ORAL RADIOLOGY
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
abnormal anatomic structures on two-dimensional images that
represent three-dimensional structures. After the search process, if
a finding is deemed abnormal, the clinician forms a mental three-
dimensional image of the abnormality that includes the precise
location, size, internal structure, and how the abnormality affects
the surrounding normal structures. This complex perceptual step
is a method of identifying features of the abnormality used to
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-
cific features of each type of abnormality and then attempt to use
this information to interpret images. This approach has been
shown to be ineffective in correct interpretation of radiographic
abnormalities. However, it has been found that understanding the
basic disease mechanism underlying the changes that each type of
abnormality can render in the diagnostic image is more effective
in enhancing a clinician’s diagnostic accuracy. The terms “disease
mechanism” and “basic science” are used to represent the patho-
physiologic basis of abnormalities at the cellular, tissue, and bio-
chemical levels. More recent research suggests that the understanding
of disease mechanisms plays an essential role in enhancing diag-
nostic accuracy in novice clinicians. Basic science knowledge
apparently creates a coherent mental representation of diagnostic
categories and their features. According to this theory, basic sci-
ences may assist in “true understanding” of the diagnostic entities
by creating coherent mental representations of different disease
categories. Hence, when clinicians understand why certain features
occur, they are able to make the diagnosis that “makes sense,”
rather than simply focusing on feature counting and rote memory.
Also, more recent research shows that teaching disease mechanisms
and radiographic features in an integrated fashion produced novice
clinicians with higher diagnostic accuracy than novice clinicians
who were taught in a segregated manner.
Worth, a pioneer in diagnostic oral radiology, stated, “Radio-
graphic appearances are governed by anatomic and physiologic
changes in the presence of disease processes. Radiologic diagnosis
is founded on knowledge of these alterations, the prerequisite
being awareness of disease mechanisms.”
ANALYSIS OF ABNORMAL FINDINGS
There are two main forms of diagnostic processing described in
radiology; the first is the analytic or systematic strategy. This
approach relies on a step-by-step analysis of all the imaging features
of an abnormal finding so that a diagnosis can be made based on
these findings (Fig. 17-1). This analytic process is believed to reduce
bias and premature closure of the decision-making process.
Learning
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
techniques used by the clinician when faced with an abnormality.
Diagnostic
strategy
The second form, a nonanalytic strategy, assumes that simply
viewing an abnormal finding automatically leads to a holistic
diagnostic hypothesis, which is followed by a deliberate search for
features that support the initial hypothesis. The nonanalytic
approach suggests that the clinician makes an automatic decision
regarding the diagnosis without thorough feature analysis of the
image. For example, expert radiologists may rely on pattern recog-
nition as a nonanalytic diagnostic strategy.
There is some empirical evidence that nonanalytic reasoning
can be successfully employed by novice clinicians. However, critics
of teaching novices to rely on nonanalytic processing argue that
the success of this diagnostic strategy is limited by the novice’s
minimal experience and the varied appearances of both normal
anatomy and pathologic disorders in images.
Although these two processes are viewed as separate mecha-
nisms, research provides evidence that they are complementary
and should not be viewed as being mutually exclusive. Students
learning oral radiology could potentially benefit from specific
training in the use of combined analytic and nonanalytic diagnos-
tic strategies.
An analytic tool for the analysis of abnormal findings is pre-
sented in the next section. The main function of this tool is to
collect all the available imaging characteristics of the abnormal
finding. Once the information is assembled, it is useful in the
diagnostic process.
As the imaging characteristics are being collected, it is impor-
tant to integrate the disease mechanism underlying these charac-
teristics when possible. For instance, Figure 17-2 depicts the
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
radiolucent in the image. In a later maturation stage, this abnor-
mality produces amorphous bone in the center (Fig. 17-2, B),
resulting in a radiopaque mass in the center surrounded by a soft
tissue radiolucent rim. Knowledge of the disease mechanism allows
for the correct diagnosis of a lesion of periapical osseous dysplasia
in an unusual location in the maxilla and after the associated tooth
has been extracted (Fig. 17-2, C).
Learning disease categories
Radiographic features and
causal connections using
disease mechanisms
Radiographic case
Analytical strategy Non-analytical strategy
Features
Location Internal structure
Size and shape Effect on surrounding
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
STEP 1: LOCALIZE ABNORMALITY
Localized or Generalized
The anatomic location and limits of the abnormality should be
described. This information aids in starting to select various disease
categories. If an abnormal appearance affects all the osseous struc-
tures of the maxillofacial region, generalized disease mechanisms,
such as metabolic or endocrine abnormalities of bone, are consid-
ered. If the abnormality is localized, one considers whether it is
unilateral or bilateral. Variations of normal anatomy are more
commonly bilateral. For instance, a bilateral mandibular radiolu-
cency may indicate normal anatomy, such as extensive subman-
dibular gland fossa. Abnormal conditions are more commonly
unilateral. For instance, fibrous dysplasia commonly is unilateral.
bilaterally in the maxillofacial region. A few abnormalities, such as
Paget’s disease and cherubism, are always seen bilaterally in the
jaws. Also, when cherubism involves the mandible, the first region
to be involved is in the midramus region, and this is the mecha-
nism behind the anterior displacement of molars (Fig. 17-3).
Position in the Jaws
Identifying the exact location of the lesion in the maxillofacial
complex aids the diagnostic process in two ways: (1) it determines
the epicenter and (2) some lesions tend to be found in specific
locations.
Determining the epicenter of the lesion or the point of origin
assists in indicating the tissue types that compose the abnormality
in question. The epicenter can be estimated on the basis of the
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
or lesions with ill-defined boundaries. Following are a few exam-
ples of relating the epicenter of the lesion to the tissue of origin:
• If the epicenter is coronal to a tooth, the lesion probably is
composed of odontogenic epithelium (Fig. 17-4).
• If it is above the inferior alveolar nerve canal (IAC), the
likelihood is greater that it is composed of odontogenic tissue
(Fig. 17-5).
• If the epicenter is below the IAC, it is unlikely to be odonto-
genic in origin (Fig. 17-6).
• If it originates within the IAC, the tissue of origin probably is
neural or vascular in nature (Fig. 17-7).
• The probability of cartilaginous lesions and osteochondromas
occurring is greater in the condylar region.
• If the epicenter is within the maxillary antrum, the lesion is
not of odontogenic tissue, as opposed to a lesion that has
grown into the antrum from the alveolar process of the maxilla
(Fig. 17-8).
The other reason to establish the exact location of the lesion is
that particular abnormalities tend to be found in very specific
locations. Following are a few examples of this observation:
• The epicenters of central giant cell granulomas commonly are
located anterior to the first molars in the mandible and anterior
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 17-9 Cropped panoramic film revealing several small, punched-out lesions of
multiple myeloma (a few are indicated by arrows) involving the body and ramus of the
mandible.
FIGURE 17-10 Lateral oblique projection of the mandible showing the well-defined
border (arrows) of a residual cyst.
differential diagnosis. For instance, when differentiating between a
dentigerous cyst and a hyperplastic follicle surrounding the coronal
portion of a tooth, size may be considered a determining factor.
Because dentigerous cysts have growth potential, they are often
much larger than a hyperplastic follicle.
STEP 2: ASSESS PERIPHERY AND SHAPE
One should study the periphery of the lesion. Is the periphery well
defined or ill defined? If an imaginary pencil can be used to draw
confidently the limits of the lesion, the margin is well defined (Fig.
17-10). The clinician should not become concerned if some small
regions are ill defined; these may be due to the shape or direction
of the x-ray beam at that particular location. A well-defined lesion
is one in which most of the periphery is well defined. In contrast,
it is difficult to draw an exact delineation around most of an
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
dimension or a zone of transition. For instance, a thin radiopaque
line or cortex at the periphery would represent a narrow zone of
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).
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
periapical osseous dysplasia and may indicate a very slow rate of
growth or the potential for the lesion to stimulate the production
of surrounding bone (see Fig. 17-2).
Soft Tissue Capsule. A radiopaque lesion may have a soft tissue
capsule, which is indicated by the presence of a radiolucent line
at the periphery. This soft tissue capsule may be seen in conjunc-
tion with a corticated periphery, as is observed with odontomas
and cementoblastomas (Figs. 17-12 and 17-13).
Ill-Defined Borders
Blending Border. A blending border is a gradual, often wide zone
of transition between the adjacent normal bone trabeculae and the
abnormal-appearing trabeculae of the lesion. The focus of this
observation is on the trabeculae and not on the radiolucent marrow

FIGURE 17-12 Thin, radiolucent periphery indicating a soft tissue capsule positioned
between the internal radiopaque structure of this odontoma and the radiopaque outer cortical
boundary (arrows).
FIGURE 17-13 Periapical image revealing a radiopaque mass associated with the root
of the first bicuspid. The prominent radiolucent periphery (arrows) is characteristic of a soft
tissue capsule of this benign cementoblastoma.
spaces. Examples of conditions with this type of margin are scleros-
ing osteitis (Fig. 17-14) and fibrous dysplasia.
Invasive Border. An ill-defined invasive border appears as an area
of radiolucency with few or no trabeculae representing bone
destruction just behind and at the leading margin of the lesion and
usually has a wide zone of transition (Fig. 17-15). In contrast to
the blending border, the focus of this observation is on the enlarg-
ing radiolucency at the expense of bone trabeculae. These borders
have also been described as permeative because the lesion grows
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
enlargement of the marrow spaces at the periphery (Fig. 17-16).
Invasive borders are usually associated with rapid growth and can
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
totally radiopaque interior is observed in osteomas. The mixed
density internal structure is seen as the presence of calcified struc-
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
or resides on either side of it; this is difficult to determine by using
two-dimensional images representing three-dimensional structures.
The shape, size, pattern, and density of the calcified structure
should be examined. For example, bone can be identified by the
presence of trabeculae. Also, the degree of radiopacity may help.
For instance, enamel is more radiopaque than bone. Following is
a list of most radiolucent to most radiopaque material seen in plain
radiographs:
• Air, fat, and gas
• 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).

FIGURE 17-18 Periapical image of a small lesion of fibrous dysplasia between the lateral
incisor and cuspid demonstrates a change in bone pattern. A greater number of trabeculae per
unit area are present, and the trabeculae are small and thin and randomly oriented in an
orange-peel pattern.
Internal Septation
Septations within a lesion represent bone that has been organized
into long strands or walls within the lesion. If these septa appear
to divide the internal structure into at least two compartments, the
term multilocular is used to describe the lesion. The origin of this
internal bone may be trapped bone, such as in ameloblastomas,
or reactive bone, such as in giant cell granulomas, or the bone may
be manufactured by the lesion, such as in ossifying fibromas. The
length, width, and orientation of the septa should be assessed. The
appearance of the septa also informs the observer about the nature
and pathology of the lesion. For instance, curved, coarse septa may
be seen in ameloblastoma giving the internal pattern a multilocu-
lar, “soap bubble” appearance. This pattern reflects the cystic for-
mations at the histologic level within the ameloblastoma as these
cystic regions remodel the trapped bone into curved shapes (Fig.
17-19, A and B). This pattern also may be observed sometimes in
odontogenic keratocysts. Another example of internal septation is
seen in giant cell granulomas. These bony septa are reactive bone
formation and in some cases represent poorly calcified osteoid and
appear as low density and wispy or granular septations in the
image. Odontogenic myxomas also exhibit internal septation. In
some cases, this tumor contains a few straight, thin septa.
Dystrophic Calcification
Dystrophic calcification is calcification that occurs in damaged soft
tissue. It is most commonly seen in calcified lymph nodes that
appear as dense, cauliflower-like masses in the soft tissue. In chroni-
cally inflamed cysts, the calcification may have a very delicate,
particulate appearance without a recognizable pattern.
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
surrounding structures (see Fig. 17-4). The following sections give
examples of effects on surrounding structures and the conclusions
that may be inferred from the behavior of the lesions.
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
(i.e., follicular cysts and occasionally odontomas) displace the
tooth apically (see Fig. 17-4, A). Because cherubism originates and
grows in the mandibular ramus, it has a propensity to push molars
in an anterior direction (see Fig. 17-3). Some lesions (e.g., lym-
phoma, leukemia, Langerhans’ cell histiocytosis) grow in the
papilla of developing teeth and may push the developing tooth in
a coronal direction (Fig. 17-20).
Resorption of teeth usually occurs with a more chronic or
slowly growing process (see Fig. 17-4, A). It may also result from
chronic inflammation. Although tooth resorption is more com-
monly related to benign processes, malignant tumors occasionally
resorb teeth.
Widening of the periodontal membrane space may be seen with
many different kinds of abnormalities. It is important to observe
whether the widening is uniform or irregular and whether the
lamina dura is still present. For instance, orthodontic movement
of teeth results in widening of the periodontal membrane space,
but the lamina dura remains intact. Malignant lesions can quickly
grow down the ligament space, resulting in an irregular widening
and destruction of the lamina dura (Fig. 17-21).
Surrounding Bone Reaction
Some abnormalities can stimulate a peripheral bone reaction. An
example is the peripheral cortex of a cyst or sclerotic border of
periapical osseous dysplasia as described in the analysis of periph-
ery. The corticated border of a cyst is not actually part of the cyst
but is a bone reaction. Identification of peripheral bone formation
provides a behavioral characteristic that suggests that the abnor-
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

FIGURE 17-20 Leukemic infiltration of the mandible showing coronal displacement of
the developing second molar (white arrow) from the remnants of its crypt (black arrow). There
is a lack of a lamina dura around the apex of the first molar and widening of the periodontal
ligament space around the second deciduous molar.
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
have maintained an outer cortical plate (see Fig. 17-4, B). A rapidly
growing lesion outstrips the ability of the periosteum to respond,
and the cortical plate may be missing (Fig. 17-22). The remodeled
external shape of the mandible or maxilla can provide information

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).
FIGURE 17-22 Axial CT image of an ameloblastoma involving the left mandibular ramus
shows significant expansion of the ramus with some periosteal bone formation (black arrow)
but with many regions of no periosteal bone formation (white arrows), which likely reflects a
fast rate of expansion by the ameloblastoma.
on the growth pattern of the entity. For instance, a tumor such as
ossifying fibroma often has a concentric growth pattern, whereas
a bone dysplasia such as fibrous dysplasia enlarges the bone with
a growth pattern that is along the bone without an obvious epi-
center (Fig. 17-23).
Exudate from an inflammatory lesion can lift the periosteum
off the surface of the cortical bone stimulating the osteoblasts of
the periosteum to lay down new bone (Fig. 17-24). When this
process occurs more than once, an onion-skin type of pattern can
be seen. This pattern is most commonly seen in inflammatory
C H AP TER 17 Principles of Radiographic Interpretation 281
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
diagnosis has been reached, ambiguities are resolved either by
searching for more features or by putting more weight on one
feature or the other. For instance, in the analysis of a hypothetical
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-
sive border and bone destruction are more important characteris-
tics and indicate a malignant process. In the analytic approach (see
Fig. 17-1), all these accumulated characteristics are used to make a
diagnostic decision. A diagnostic algorithm such as shown in
Figure 17-26 can aid in this decision-making process. Following
this algorithm, the observer makes decisions regarding which
general category the entity fits into and then proceeds to smaller,
more specific categories. This is not an infallible method because
any algorithm occasionally may fail because lesions sometimes do
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).

Image analysis
algorithm
Normal Abnormal
Acquired Developmental
Benign
Cyst
neoplasm
Malignant
Inflammatory
neoplasm
Bone
Vascular
dysplasia
Metabolic Trauma
FIGURE 17-26 Algorithm representing the diagnostic process that follows evaluation of
the radiographic features of an abnormality.
Decision 1: Normal or Abnormal
The clinician should determine whether the structure of interest is
a variation of normal or represents an abnormality. This is a crucial
decision because variations of normal do not require treatment or
further investigation. However, as previously stated, to be profi-
cient in the interpretation of diagnostic images, the clinician needs
an in-depth knowledge of the various appearances of normal
anatomy.
Decision 2: Developmental or Acquired
If the area of interest is abnormal, the next step is to decide whether
the radiographic characteristics (location, periphery, shape, internal
structure, and effects on surrounding structures) indicate that the
region of interest represents a developmental abnormality or an
acquired change. For instance, the observation that a tooth has an
abnormally short root leads to the pertinent question, “Did the
tooth develop a short root, or was the root at one time of normal
length and has become shorter?” If the answer is the latter, the
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-
fication. In contrast, external root resorption may shorten the root,
but the canal remains visible to the end of the root (Fig. 17-27).
Decision 3: Disease Classification
If the abnormality is acquired, the next step is to select the most
likely disease category of the acquired abnormality. The disease
category can be established through observing the features and
how they reflect a particular disease mechanism. The categories
may include cysts, benign tumors, malignant tumors, inflamma-
tory lesions, bone dysplasias (fibro-osseous lesions), vascular
abnormalities, metabolic diseases, or physical changes such as frac-
tures. The following chapters describe the characteristic radio-
graphic findings based on the disease mechanisms of these
abnormalities. The analysis should strive at least to narrow the
C H AP TER 17 Principles of Radiographic Interpretation 283
A B C
FIGURE 17-27 A-C, Periapical films revealing external resorption of the maxillary
incisors, which is an acquired abnormality because of the presence of the wide pulp chambers
at the apex of the roots of the teeth.
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,
such as patient history and clinical signs and symptoms, into the
decision-making process. When possible, considering this informa-
tion at the end helps avoid the problem of doing an incomplete
search of the images or trying to make the radiographic character-
istics fit a preconceived diagnosis.
Decision 4: Ways to Proceed
After analyzing the images, the clinician must decide in what way
to proceed. This decision may require further imaging, treatment,
biopsy, or observation of the abnormality (watchful waiting). For
example, if the lesion fits in the malignant category, the patient
first should be referred to an oral and maxillofacial radiologist to
complete the diagnostic imaging to stage the lesion and select the
biopsy site and then should be referred to a surgeon for biopsy
and treatment. Periapical osseous dysplasia may not require any
further investigation or treatment. In other cases, a period of
watchful waiting, followed by reexamination in a few months, may
be indicated if the abnormality appears benign and no clear need
for immediate treatment exists.
With advanced training or experience in diagnostic imaging,
the clinician may be able to name one specific abnormality or at
least make a short list of entities from one of the divisions of
acquired abnormalities. When analyzing diagnostic images, it is
advisable to create a formal report for the purposes of documenta-
tion and communication with other clinicians.
WRITING A DIAGNOSTIC IMAGING REPORT
The radiographic report can be subdivided into the following
subsections.
PATIENT AND GENERAL INFORMATION
This section appears at the beginning and contains the following
information: address of the radiology clinic; the date of the dicta-
tion; the referring clinician’s name and clinic or address; and the
patient’s name, age, sex, and any numeric identification such as a
clinic or medical registration number.
IMAGING PROCEDURE
This section gives a list of the imaging procedures provided along
with the date of the examination. An example could be the fol-
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
administration of contrast material made on February 20, 2012.
CLINICAL INFORMATION
This is an optional section that includes pertinent clinical informa-
tion regarding the patient provided by the referring clinician or
the clinician dictating the report if a clinical examination was made
before the radiologic examination. The clinical information should
remain brief and summarize the information pertaining to the
lesion in question. For example: mass in floor of mouth, possible
ranula, and patient has a history of lymphoma.
FINDINGS
This section comprises an objective detailed list of observations
made from the diagnostic images. This can follow the previously
presented step-by-step analysis of the extent of the lesion, periph-
ery and shape, internal structure, and effects on surrounding struc-
tures. This section does not include an interpretation.
INTERPRETATION
This section is shorter and provides an interpretation for the pre-
ceding observations. The clinician should endeavor to provide a
definitive interpretation. When this is not possible, a short list of
conditions or a differential diagnosis (in order of likelihood) is
acceptable. In some situations, advice regarding additional studies,
when required, and treatment may be included. Lastly, the name
and signature of the clinician composing the report is included.
SELF-TEST
To practice the analytic technique presented, the reader should
examine Figure 17-4, A and B, and write down all observations
and the results of the diagnostic algorithm before reading the fol-
lowing section.
DESCRIPTION
Location
The abnormality is singular and unilateral, and the epicenter lies
coronal to the mandibular first molar.
Periphery and Shape
The lesion has a well-defined cortical boundary and a spherical or
round shape. The periphery also attaches to the cementoenamel
junction.
Internal Structure
The internal structure is totally radiolucent.
Effects
This lesion has displaced the first molar in an apical direction,
which reinforces the decision that the origin was coronal to this
tooth. Also, the lesion has displaced the second molar distally and
the second premolar in an anterior direction. Apical resorption of
the distal root of the second deciduous molar has occurred. The
occlusal radiograph reveals that the buccal cortical plate has
expanded in a smooth, curved shape, and a thin cortical boundary
still exists.
Analysis
Making all the observations is an important first step; the following
is an analysis built on these observations. To accomplish this next
step, further knowledge of pathologic conditions and a certain
amount of practice are required. The first objective is to select the
correct category of diseases (e.g., inflammatory, benign tumor,
cyst); at this point, the clinician should try not to let all the names
of specific diseases be overwhelming.
These images reveal an abnormal appearance. The coronal
location of the lesion suggests that the tissue making up this
abnormality probably is derived from a component of the dental
follicle. The effects on the surrounding structures indicate that
this abnormality is acquired. The displacement and resorption of
teeth, intact peripheral cortex, curved shape, and radiolucent inter-
nal structure all indicate a slow-growing, benign, space-occupying
lesion, most likely in the cyst category. Odontogenic tumors, such
as an ameloblastic fibroma, may be considered but are less likely
because of the shape. The most common type of cyst in a fol-
licular location is a dentigerous cyst. Odontogenic keratocysts
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,
with odontogenic keratocyst and ameloblastic fibroma as possibili-
ties in the differential diagnosis but less likely. Treatment usually
is indicated for follicular cysts, and the patient should be referred
for surgical consultation.
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