Dental Radiology

Enhanced CPD DO C

Nicholas Drage

Simon Haworth

Soft Tissue Calcification seen on

Dental Radiographs
Abstract: Soft tissue calcification is common and has a range of causes. Calcified tissues in the face and neck can produce radiopacities on
dental imaging, which, in some cases, could be mistaken for radiopaque lesions within the jaws. This article describes some of the most
common radiopacities, with examples of their typical appearances on dental radiographs and brief comments on their clinical relevance
and suggested management.
CPD/Clinical Relevance: It is important to distinguish between soft tissue radiopacities and radiopaque lesions of the jaws as these have
different management.
Dent Update 2022; 49: 713–716

Solid calcium salts give teeth and bones body and the greater cornu of hyoid can be
their characteristic radiopaque appearances. seen on a panoramic radiograph near the
Disruption of tissue physiology can bottom of the image (Figure 1). As the hyoid
cause calcium to be deposited in soft bone does not articulate with any other
tissues, leading these tissues to become bones, it is highly mobile and will move
radiopaque. Calcification can result from depending on patient positioning and the
a range of biological events including position of the tongue. Sometimes the
inflammation, infection, trauma, systemic shadow of the hyoid can be superimposed
metabolic problems and can be idiopathic on the body of the mandible (Figure 2).
where no clear cause is found.1 When this If this is the case, care must be taken not
occurs in the face and neck, the radiopaque to mistake the resultant radiopacity for
soft tissue may be superimposed over the disease. In children, the hyoid bone is
jaws and can mimic a radiopaque lesion. incompletely ossified and the body and
When assessing radiopaque structures greater cornu of hyoid may appear as Figure 1. Sectional panoramic image showing
in the neck, it is important to first identify separate radiopacities. Hyoid radiopacities (a) the body and (b) greater cornu of the
the hyoid bone, which is an important are part of the normal radiographic hyoid bone.
radiopaque landmark in the neck. The hyoid anatomy of the neck and do not need
bone is located in the anterior neck and further investigation or management.
provides support for the muscles of the In addition to the hyoid, one or more of
tongue, floor of mouth and larynx. It is part the following soft tissue calcifications may Laryngeal cartilages
of the normal neck anatomy. Generally, the be seen on dental radiographs. The larynx contains multiple cartilage
elements of which two can be seen on
panoramic imaging.
The thyroid cartilage is the largest of
Nicholas Drage, BDS, FDSRCS, FDSRCPS, DDRRCR, Consultant in Dental and Maxillofacial
the laryngeal cartilages and is composed
Radiology, University Dental Hospital, Cardiff and Vale University Health Board, Cardiff.
of hyaline cartilage. It can become calcified
Simon Haworth, BDS, PhD, MFDS RCS (Ed), NIHR Academic Clinical Fellow / Specialty
with age and become visible on panoramic
Trainee in Dental and Maxillofacial Radiology, Bristol Dental School, University of Bristol.
radiographs. Usually it is just the superior
email: nicholas.drage@wales.nhs.uk
cornu that can be seen (Figure 3); however,

October 2022 DentalUpdate 713

Dental Radiology
Figure 2. Sectional panoramic image showing
the body of hyoid (arrowed), superimposed over
the mandible.
Figure 3. Sectional panoramic image showing
(a) the triticeous cartilage located between (b)
the greater cornu of the hyoid bone and (c) the
superior cornu of the thyroid cartilage.
Figure 4. Sectional panoramic image showing
the transverse foramen of C2 (arrowed).
the thyroid cartilage lamina may also
calcify. The thyroid cartilage is located
inferior to the greater cornu of the hyoid
bone. Thyroid cartilage calcification
714 DentalUpdate October 2022
Figure 5. Sectional panoramic image showing
calcification of the right stylohyoid ligament
(arrows) with pseudo-articulation.
Figure 6. Sectional panoramic image
showing calcified plaques in the right carotid
bifurcation (arrowed).
does not require further imaging
or management.
The triticeous cartilage is a small
cartilage element in the thyrohyoid
membrane, which is present in some, but
not all, individuals. When present, the
triticeous cartilage can calcify and is visible
as a small radiopacity between the greater
cornu of the hyoid bone and the superior
cornu of the thyroid cartilage in around 8%
of patients aged over 60 years.2 These tend
to be oval in shape (triticeous= resembling
a triticum = a grain of wheat) with a smooth
border (Figure 3). The triticeous cartilage is
located at the level of the third and fourth
cervical vertebrae and can sometimes
mimic a calcified atheroma in the common
carotid artery, which is also found at
the same horizontal level;3 however, the
triticeous cartilage should be oval with
a smooth border, whereas an atheroma
will appear more linear and irregular.2
Occasionally the transverse foramen of C2 is
visible on panoramic radiographs (Figure 4),
which can provide an additional anatomical
landmark for quickly identifying the third
and fourth cervical vertebrae. Triticeous
cartilage calcification does not require
further imaging or follow-up.
Calcification of the
stylohyoid ligament
The stylohyoid ligament originates at the
styloid process and inserts into the lesser
cornu of the hyoid bone. Calcification
of the ligament is seen in 4–28% of the
population,4 and it is more common for the
calcification to be bilateral. The calcification
may be uniform, segmented or even
pseudo-articulated (Figure 5).5
The normal length of the styloid process
is up to 25 mm. However, it may measure
slightly more on a panoramic radiograph
due to the inherent magnification with the
technique. However, if the styloid process
is >30 mm it can be considered elongated.6
Elongation of the styloid process or
calcification of the ligament is usually
asymptomatic, but a small number of
people experience symptoms. This is known
as Eagle’s syndrome and is characterized by
facial, oropharyngeal and/or neck pain.7,8 If
you suspect a patient has Eagle’s syndrome
based on their panoramic radiograph and
symptoms, then a non-urgent secondary
care referral is recommended.
Carotid artery calcification
Calcification within atheromatous plaques
within the carotid bifurcation appear
either as radiopaque nodular masses or as
two radiopaque vertical lines9 in the soft
tissues anterior to the cervical spine at the
junction between C3 and C4 (Figure 6). The
prevalence of carotid calcifications (shown
on panoramic radiographs) is 3–5%.10
The presence of atheromatous plaques
on panoramic radiography may be a risk
predictor for cerebrovascular accident11,12
and an indicator of hypertension and
ischaemic heart disease.13,14 Therefore, if
calcified plaques are seen, consideration
should be given to informing the general
medical practitioner.
Tonsilloliths
Calcification within the crypts of the
palatine tonsils has characteristic

b multiple small opacities from osteoma
Figure 7. Sectional panoramic image showing
multiple small tonsilloliths in the right palatine
tonsil (arrows).
Figure 8. Sectional panoramic image showing
a calcified left jugulodigastric lymph node (left
level II) (arrow).
Figure 9. Sectional panoramic image showing a
calculus in the hilum of the right submandibular
gland (arrow).
appearance on panoramic radiographs –
multiple small round/oval radiopacities
superimposed on the ramus of the
mandible (Figure 7). In some cases, ghost
shadows of the radiopacities are also
October 2022 DentalUpdate 715
Figure 10. (a) Sectional panoramic image
showing a calculus in the left submandibular
extra-glandular duct (arrowed) superimposed
over the body of mandible. (b) Lower 90° occlusal
image of the same patient clearly demonstrating
the calculus (arrowed).
present on the contralateral side of the
mandible. The clinical significance of
tonsilloliths is that they can be associated
with halitosis.15,16 They are a common
incidental finding, and no further
investigations are required to make
the diagnosis.
Lymph node calcification
Dystrophic calcification within cervical
lymph nodes is most often associated
with infection/ inflammation, typically
tuberculosis or healed necrotic abscesses.17
The nodes are asymptomatic and appear as
well-defined cauliflower like radiopacities
at or below the angle of the mandible or
below the lower border of the mandible
(Figure 8). If there is a satisfactory
explanation in the patient’s medical history
and the patient is asymptomatic then no
further tests are required.
Dental Radiology
Figure 11. Peri-apical radiograph showing
cutis (arrows).
Figure 12. Sectional panoramic image showing
several phleboliths, superimposed over the
left angle of mandible. One of the phleboliths
(arrowed) demonstrates the classical appearance
with a more radiolucent centre.
Salivary calculi
Salivary calculi may cause pain and
swelling of the affected gland when eating.
Submandibular gland calculi are more
common than parotid gland calculi.18
Submandibular calculi are more likely to
be calcified and therefore visible on plain
radiographs. However, both parotid and
submandibular calculi may be detected
on panoramic imaging.19 On a panoramic
radiograph, submandibular calculi are
typically well-defined smooth radiopacities,
which may be laminated. If they are located
at the hilum or within the gland, they will
be seen at the lower border of the mandible
(Figure 9), but if they are within the main
extra-glandular duct, they will become
superimposed on the mandible and may
mimic a dense bone island (Figure 10a).
If this is the case, further views, such as a
lower occlusal radiograph, may be needed
to confirm the presence of a calculus
(Figure 10b). Calculi within the gland or
hilum tend to be round, whereas those
located within the main duct tend to be
more oval/lozenge shaped. Depending
on the size and location of the calculus,
it may be possible to treat the calculus
Dental Radiology
using a minimally invasive technique,
such as basket retrieval or lithotripsy.
Specialist referral is therefore suggested
for patients who have a salivary calculus
with symptoms from the affected gland.
Typically, patients who are symptomatic
from a salivary calculus will complain of
pain or swelling that occurs when eating.
Osteoma cutis
Osteoma cutis of the facial tissues
represents a primary or secondary
formation of ossific foci within the
skin,20 often as a result of acne scarring.
Radiographically, it presents as multiple
small radiopacities in the lips or cheeks
(Figure 11). No further imaging or
management is required.
Phleboliths
Phleboliths are formed when a thrombus
within a vessel calcifies. They are
associated with slow-flow vascular
anomalies, such as venous malformations,
and are said to be pathognomonic
for this particular condition.21 On a
panoramic radiograph, they are rounded
radiopacities in the region of the venous
malformation, which characteristically
have a more radiolucent centre
(‘doughnut appearance’) (Figure 12). It
is thought that the radiolucent centre
represents the lumen of the vessel. If a
venous malformation is suspected, then
referral to oral and maxillofacial surgery is
recommended. Ultrasound and magnetic
resonance imaging are often required to
assess the full extent of the malformation,
and to plan treatment.
Other conditions
Myositis ossificans is a rare condition
leading to calcification of muscle.
This occurs sporadically following
trauma, and in a very rare and severe
inherited form termed fibrodysplasia
ossificans progressiva. The radiographic
appearance is variable, but may show
linear radiopaque streaks in the same
orientation as the muscle fibres.
Conclusions
Soft tissue opacities in the neck and
face are common and relatively few
opacities require further imaging or
follow-up. By adopting a systematic
approach and paying close attention to
716 DentalUpdate October 2022
the shape and location of radiopacities
it is usually possible to distinguish
between the different opacities
described in this article and decide on
suitable management.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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