Radiologic Interpretation Part 2. Dr Dayea Oh OMF Radiologist Dr Dayea Oh OMF Radiologist # Learning Objectives • Reviewing the systematic approach • Describing “lesions” considering: • Location • Borders • Morphology • Internal Architecture / Pattern • Effects on Adjacent Tissues • Understanding Surgical Sieve • Choosing next appropriate diagnostic imaging modality for further evaluation • Knowing when to urgently refer - Reviewing the systematic approach - Describing “lesions” considering: - Location - Borders - Morphology - Internal Architecture / Pattern - Effects on Adjacent Tissues - Understanding Surgical Sieve - Choosing next appropriate diagnostic imaging modality for further evaluation - Knowing when to urgently refer Systematic approach 00. Any Technical or Positional Error? 1. Address Clinical Concerns 2. Dentoalveolar a) Count teeth & identify ectopic and/or impacted teeth b) Dental Anomalies (Position, Shape,...) c) Periodontal bone loss d) Dental pathology (non-carious tooth loss, caries, fracture, periapical pathologies, etc.) 3. Maxilla and Mandible a) **Abnormal lucencies** b) **Abnormal opacities** c) Altered trabecular pattern d) Fractures e) Jaw Asymmetry 4. Maxillary sinuses (esp. mucosal changes) 5. TM Joints (esp. morphological change of condyles) 6. Soft Tissues (swelling, soft tissue calcifications eg. Tonsiloliths, salivary gland stones, etc. ) 7. Other sites: Spine, orbits, etc. (structural changes) 00. Any Technical or Positional Error? 1. Address Clinical Concerns 2. Dentoalveolar - a) Count teeth & identify ectopic and/or impacted teeth - b) Dental Anomalies (Position, Shape, ...) - c) Periodontal bone loss - d) Dental pathology (non-carious tooth loss, caries, fracture, periapical pathologies, etc.) 3. Maxilla and Mandible - a) **Abnormal lucencies** - b) **Abnormal opacities** - c) Altered trabecular pattern - d) Fractures - e) Jaw Asymmetry 4. Maxillary sinuses (esp. mucosal changes) 5. TM Joints (esp. morphological change of condyles) 6. Soft Tissues (swelling, soft tissue calcifications eg. Tonsiloliths, salivary gland stones, etc.) 7. Other sites: Spine, orbits, etc. (structural changes) Abnormal Findings (Lesions) in the Jaws **1.** Lucent? Opaque? Or Mixed? **2.** Localisation * Unilateral or Bilateral? * Single or Multiple? * Epicentre * Pericoronal / Periapical to Tooth? * **MD** Body ➝ Superior / Inferior to Mandibular Canal or Within? * **MX** ➝ Inferior or Superior to Maxillary Sinus Floor? * Other: **MD** condyle, ramus, angle, etc.    Abnormal Findings (Lesions) in the Jaws **1.** Lucent? Opaque? Or Mixed? **2.** Localisation - Unilateral or Bilateral? - Single or Multiple? - Epicentre - Pericoronal / Periapical to Tooth? - **MD** Body ➝ Superior / Inferior to Mandibular Canal or Within? - **MX** ➝ Inferior or Superior to Maxillary Sinus Floor? - Other: **MD** condyle, ramus, angle, etc. Clinical radiograph showing a large, well-defined, unilocular radiolucent lesion in the posterior mandible. The lesion surrounds the crown of an unerupted tooth (likely a wisdom tooth), consistent with a dentigerous cyst or odontogenic keratocyst. Occlusal radiograph displaying multiple bilateral radiopaque and mixed-density lesions scattered throughout both the maxilla and mandible. This presentation is characteristic of conditions such as florid osseous dysplasia or ossifying fibromas. Lateral radiograph of the mandible highlighting cortical bone changes. Black arrows point to thinned or expanded buccal cortex, while white arrows indicate internal trabecular irregularities, demonstrating the 'Epicentre' localisation concepts mentioned in the text (MD condyle/ramus).       Dental radiograph (likely a cropped panoramic or periapical view) showing teeth and bone structure in the posterior mandible region. Dental radiograph of the mandibular anterior region with two black arrows pointing to a radiolucent area at the apex of a tooth root, suggestive of pathology such as a periapical cyst or granuloma. Lateral oblique dental radiograph of the mandible showing multiple teeth. Three white arrows point to a large, well-defined radiolucent lesion in the body of the mandible, likely indicating a pathological process such as an odontogenic tumor or cyst. Close-up dental radiograph of the mandibular angle showing a single, round, well-circumscribed radiolucent lesion surrounded by normal bone trabeculae. Lateral view dental radiograph showing a large, oval-shaped radiolucent lesion within the mandibular ramus/angle region, displacing surrounding structures. Intraoral periapical radiograph of the posterior mandible showing a large, dome-shaped radiolucency associated with the roots of molars. Two white arrows indicate the superior border of the lesion. # Abnormal Findings (Lesions) in the Jaws ## 3. Borders - Well defined / Ill (poorly) defined - Well defined ⟶ Corticated, Sclerotic, etc. - Circular, Scalloping, Irregular... ## 4. Morphology - Unilocular (circular border), Multilocular, Pseudo-multilocular - Other: circular, ovoid, triangular, ...     #### Abnormal Findings (Lesions) in the Jaws ##### 3. Borders - Well defined / Ill (poorly) defined - Well defined ⟶ Corticated, Sclerotic, etc. - Circular, Scalloping, Irregular... ##### 4. Morphology - Unilocular (circular border), Multilocular, Pseudo-multilocular - Other: circular, ovoid, triangular, ... Radiograph of a mandible showing a well-defined, unilocular radiolucent lesion with a corticated border. Radiograph of a mandible showing a multilocular radiolucent lesion with scalloping between the roots of the teeth. Radiograph of a mandible showing an irregular, poorly defined radiolucent lesion with ill-defined borders. Radiograph of a mandible showing a large, triangular radiolucent lesion with scalloping along the inferior border of the jaw. Abnormal Findings (Lesions) in the Jaws 5. Internal Architecture / Structure (lucent lesion) • Completely lucent? • Septa, calcifications, tooth-like structure, etc. 6. Pattern (opaque lesion) • Homogenous / Heterogenous • Altered trabecular bone • Ground glass, wheel-spoke, popcorn-like, etc.   #### Abnormal Findings (Lesions) in the Jaws ##### 5. Internal Architecture / Structure (lucent lesion) - Completely lucent? - Septa, calcifications, tooth-like structure, etc. ##### 6. Pattern (opaque lesion) - Homogenous / Heterogenous - Altered trabecular bone - Ground glass, wheel-spoke, popcorn-like, etc. Radiograph of a mandible showing a lucent lesion with internal architecture. The image displays multiple septa and calcifications within the lesion, consistent with the text description of 'Internal Architecture / Structure (lucent lesion)'. Radiograph of a mandible showing an opaque lesion with a pattern. The image demonstrates altered trabecular bone, potentially illustrating patterns like ground glass or wheel-spoke mentioned in the text under 'Pattern (opaque lesion)'. Abnormal Findings (Lesions) in the Jaws 7. Effects on Adjacent Structures * **Teeth:** lamina dura, PDL space, root, follicular space * **Mandibular Canal:** * Displacement, compression / flattening, widening, obliteration * **Surrounding Bone:** * Sclerosis * **Cortical plate:** * Expansion, thinning, effacement * Periosteal reaction / new bone formation * Lamellar / Onion-skin / Hair-on-end / Sunray / Codman’s triangle, etc. * **Maxillary sinus:** * **Floor:** lifting, effacement, discontinuity, remodelling, etc. * **Other walls:** discontinuity, remodelling, inward bowing, etc.  #### Abnormal Findings (Lesions) in the Jaws ##### 7. Effects on Adjacent Structures - **Teeth:** lamina dura, PDL space, root, follicular space - **Mandibular Canal:** - Displacement, compression / flattening, widening, obliteration - **Surrounding Bone:** - Sclerosis - **Cortical plate:** - Expansion, thinning, effacement - Periosteal reaction / new bone formation - Lamellar / Onion-skin / Hair-on-end / Sunray / Codman’s triangle, etc. - **Maxillary sinus:** - **Floor:** lifting, effacement, discontinuity, remodelling, etc. - **Other walls:** discontinuity, remodelling, inward bowing, etc. Radiograph showing abnormal findings in the jaws. The image displays a section of the mandible with teeth on the right side and a large radiolucent lesion in the body of the jaw. Arrows point to specific features: one indicates displacement or widening of the inferior alveolar canal (mandibular canal), while another points to the expansion and thinning of the cortical plate caused by the lesion. | | | | | | |:---|:---|:---|:---|:---| | **Artefactual** | **Anatomical** | **Anomaly** | **Inflammatory / Infection** | **Cysts / Cyst-like Lesions** | | **Hamartoma** | **Benign Tumour**<br>• Odontogenic<br>• Non- odontogenic | **Idiopathic** | **Fibro-osseous Lesions** | **Malignancy** | | **Trauma** | **Vascular Anomalies** | **Metabolic / Systemic Disease** | **Other (giant cell lesion, syndromes, etc.)** | |  | Artefactual | Anatomical | Anomaly | Inflammatory / Infection | Cysts / Cyst-like Lesions | |:---|:---|:---|:---|:---| | **Hamartoma** | **Benign Tumour**<br>• Odontogenic<br>• Non-odontogenic | **Idiopathic** | **Fibro-osseous Lesions** | **Malignancy** | | **Trauma** | **Vascular Anomalies** | **Metabolic / Systemic Disease** | **Other (giant cell lesion, syndromes, etc.)** | | Labelled diagram: A flowchart titled 'Surgical Sieve – Identifying the nature of the lesion'. It displays a hierarchical classification of lesions organized into three rows. The top row contains five categories: Artefactual, Anatomical, Anomaly, Inflammatory / Infection, and Cysts / Cyst-like Lesions. The middle row includes Hamartoma, Benign Tumour (subdivided into Odontogenic and Non- odontogenic), Idiopathic, Fibro-osseous Lesions, and Malignancy. The bottom row features Trauma, Vascular Anomalies, Metabolic / Systemic Disease, and Other (giant cell lesion, syndromes, etc.).  Dental radiograph (panoramic X-ray) showing the maxillary and mandibular arches. Visible annotations include 'Sinus locule' pointing to a cavity in the maxilla, and '*opacity= displaced root fragment' indicating a radiopaque area within the sinus region. Anomaly Cleft palate (congenital) Always look for other anomalies esp dental anomalies eg. supernumerary teeth, malformed teeth, missing teeth, etc.    - Cleft palate (congenital) - Always look for other anomalies, especially dental anomalies (e.g., supernumerary teeth, malformed teeth, missing teeth, etc.) Radiograph (X-ray) of a mandible showing multiple dental anomalies. The image displays several malformed and supernumerary teeth, consistent with the text note about looking for dental anomalies such as supernumerary, malformed, or missing teeth. Radiograph (X-ray) of a maxilla demonstrating a cleft palate (congenital). The image shows the skeletal defect in the hard palate area and associated dental irregularities. Cross-sectional medical imaging scan (likely CT) of the nasal/oral region. It highlights the anatomy of the soft tissue coverage overlying the bony structures. # Stafne Defect ## OPG Well-defined lucency with heavily / thick corticated border ## CT Cortical depression (often fat-filled, seldom salivary gland) CT review      #### OPG - Well-defined lucency with heavily/thick corticated border #### CT - Cortical depression (often fat-filled, seldom salivary gland) - CT review Radiograph (OPG) showing a well-defined radiolucent area in the mandible with a heavily corticated border. Radiograph showing a Stafne defect in the mandible. Radiograph showing a Stafne defect in the mandible. CT scan (axial view) showing a cortical depression in the mandible. CT scan (axial view) showing a cortical depression in the mandible. Caption notes that it is often fat-filled and seldom associated with the salivary gland. Inflammatory Lucent → Mixed lucent-sclerotic → Sclerotic Discontinuity / effacement of Mx sinus floor Sinus locule*  - Lucent → Mixed lucent-sclerotic → Sclerotic - Discontinuity/effacement of maxillary sinus floor - Sinus locule* Clinical radiograph (panoramic X-ray) of the maxillofacial region showing inflammatory changes in the maxillary sinus. Key annotated features include: 'Discontinuity / effacement of Mx sinus floor' pointing to the disrupted bony boundary of the maxillary sinus; and 'Sinus locule*' indicating a compartmentalized air space within the sinus. The image also includes a directional marker 'L' for left side. This visual demonstrates diagnostic findings relevant to sinus pathology. **Inflammatory**  **Inflammatory** Clinical radiograph of the mandible and maxilla showing a large area of reactive sclerosis in the posterior mandible. The image demonstrates increased bone density consistent with chronic inflammatory response. **Cyst** Cysts are **EXPANSILE** and have **CORTICATED** borders **Radicular Cyst** [] **FIG. 23.1** The balloon-like "**hydraulic**" enlargement of a cyst in the jaws, and displacement of the adjacent inferior alveolar canal as it increases in size. Corticated borders = slow growing lesion Further investigation with CBCT or MDCT   - Cysts are **expansile** and have **corticated** borders. - Corticated borders = slow growing lesion. - Further investigation with CBCT or MDCT. - The balloon-like "hydraulic" enlargement of a cyst in the jaws, and displacement of the adjacent inferior alveolar canal as it increases in size. Medical diagram illustrating the cross-section of teeth and jawbone showing a large cyst causing hydraulic expansion and displacing the inferior alveolar canal. Dental radiograph (X-ray) showing an expansile radicular cyst centered at tooth #13, with text annotation indicating elevation of the sinus floor and relationship to endodontic treatment. **Cyst** - Well-defined corticated expansile lesion centred at the apical foramen of 23, extending labially and also inferiorly over the labial aspect of the root - Labial expansion with cortical thinning and focal effacements - Elevated cortical floor of the left maxillary sinus - Internal homogeneous fluid attenuation. This lesion is well contained in spite of the focal effacements of the labial cortex  - Well-defined corticated expansile lesion centred at the apical foramen of 23, extending labially and also inferiorly over the labial aspect of the root - Labial expansion with cortical thinning and focal effacements - Elevated cortical floor of the left maxillary sinus - Internal homogeneous fluid attenuation. This lesion is well contained in spite of the focal effacements of the labial cortex Composite medical imaging figure consisting of three panels labeled (a), (b), and (c). Panel (a) is a sagittal view showing a well-defined corticated expansile lesion centred at the apical foramen of tooth 23, extending labially and inferiorly. Panel (b) is an axial view demonstrating labial expansion with cortical thinning and focal effacements, as well as an elevated cortical floor of the left maxillary sinus. Panel (c) is another axial view highlighting internal homogeneous fluid attenuation within the lesion, which remains well contained despite focal effacements of the labial cortex. **Cyst** CBCT / MDCT review  CBCT / MDCT review A composite figure containing three radiographic views demonstrating a dentigerous cyst. The left panel (labeled A) is a periapical radiograph showing a large radiolucent lesion (indicated by white arrows) surrounding the crown of an unerupted tooth. The right panels are CBCT/MDCT slices (axial and coronal) confirming the cystic nature of the lesion in relation to the unerupted tooth structure. # Cyst CBCT review    CBCT review Composite radiograph showing two views of a large radiolucent lesion in the mandible, labeled 'Odontogenic Keratocyst'. The images demonstrate the cystic nature and extent of the lesion relative to surrounding teeth. Panoramic radiograph (MDCT review) displaying the full dental arches. It serves as a comparative view for the cystic pathology shown in the upper panels. Radiographic image showing a radiolucent area in the anterior maxilla, indicated by black arrows. A white arrow points to the incisive canal region. Labeled 'CBCT review', it illustrates an Incisive canal cyst or nasopalatine duct cyst. # Pseudocyst (Cyst-like Lesion) ## Simple Bone Cyst Corticated lucency. Can be mildly expansile. MDCT/MRI Review    - **Simple Bone Cyst**: Corticated lucency. Can be mildly expansile. - MDCT/MRI Review Panoramic radiograph showing a corticated lucency in the mandible. The text below notes it can be mildly expansile. Two intraoral periapical radiographs demonstrating tooth roots and surrounding bone structure. Cross-sectional CT scan image showing bony structures with an associated caption stating 'Rarely expansile'. **Harmatoma (Tumour-like Lesions)** ODONTOOMA / odontome (Compound & Complex type) amorphous mix of calculated dental tissues CT (CBCT or MSCT/MCDT) Review Refer to Surgeon     #### Hamartoma (Tumour-like Lesions) - Odontoma (Compound & Complex type): amorphous mix of calcified dental tissues - CT (CBCT or MSCT/MDCT) Review - Refer to Surgeon Clinical radiograph (CBCT slice) showing a complex odontoma. The image displays a mass of mixed calcified dental tissues in the maxilla, appearing as a heterogeneous opacity. Radiograph showing multiple distinct tooth-like structures embedded within the jawbone, consistent with a compound odontoma or multiple impacted teeth. Lateral view radiograph demonstrating an amorphous, cloud-like mass of calcified dental tissues, characteristic of a complex odontoma located in the mandible. Axial CT scan (CBCT/MSCT) displaying bilateral lesions in the mandible. On the right side (viewer's left), there is a well-defined round lesion resembling an impacted tooth (compound odontoma). On the left side (viewer's right), there is a large, irregular mass of calcified tissue (complex odontoma). Benign Odontogenic Tumour “Mass effect” Expansile features + Resorption Original outer cortex Benign lesion Erosion of endoosteal surface Periosteum Displaced bone surface **A** **B** **FIG. 24.1** **C** **Erosion of** **Endosteal** **D** MDCT/MRI Review Refer to Surgeon   - Mass effect - Expansile features + resorption - Original outer cortex - Benign lesion - Erosion of endosteal surface - Periosteum displaced bone surface - MDCT/MRI Review - Refer to Surgeon Labelled diagram illustrating the growth of a benign odontogenic tumour. Panel A shows a small lesion; Panel B shows an enlarged lobulated mass causing expansion; Panel C details the erosion of the endosteal surface and displacement of the bone cortex by periosteum; Panel D depicts the displacement of adjacent teeth. Radiograph showing a radiolucent lesion in the mandible with associated dental displacement. Benign Odontogenic Tumour Well-defined, expansile, multilocular lucency with thick, curved internal septa resulting "soap bubble" appearance MDCT/MRI Review Refer to Surgeon      - Well-defined, expansile, multilocular lucency with thick, curved internal septa resulting in "soap bubble" appearance - MDCT/MRI Review - Refer to Surgeon Axial CT scan of the mandible showing a large, expansile, multilocular radiolucency with thick, curved internal septa creating a 'soap bubble' appearance. The lesion involves multiple teeth and causes significant cortical expansion. Coronal or sagittal CT slice showing an expansile radiolucent lesion in the anterior maxilla/mandible region, demonstrating the internal architecture described as 'soap bubble' appearance. Coronal CT slice through the maxillary sinus area showing extensive bony destruction and replacement by a multilocular radiolucent lesion involving adjacent teeth roots. Panoramic radiograph (A) and periapical radiograph (B). Panel A shows a panoramic view of the jaw with a large, multilocular radiolucent lesion causing displacement of teeth. Panel B is a zoomed-in view showing the lesion's effect on tooth roots and surrounding bone structure. Periapical radiographs labeled A and B showing recurrent ameloblastoma lesions. These images display radiolucent areas around tooth roots, indicating the recurrence of the tumor after previous treatment. **Benign Non-odontogenic Tumour** **Fusiform, expansile lucency associated with mandibular canal** **Neurofibroma (strong association with Neurofibromatosis type 1 (NF1)** MDCT/MRI Review Refer to Surgeon  - Fusiform, expansile lucency associated with mandibular canal - Neurofibroma (strong association with Neurofibromatosis type 1 (NF1)) - MDCT/MRI Review - Refer to Surgeon Composite radiograph labeled 'A' and 'B' showing the mandible. The images display a fusiform, expansile radiolucency located along the inferior border of the mandible, tracking with the mandibular canal. This finding is consistent with a neurofibroma.  Medical radiograph (panoramic dental X-ray) showing the mandible and maxilla with labeled anatomical structures. The image includes two distinct bony growths: 'Torus palatinus' on the hard palate of the upper jaw and 'Lingual torus' on the lingual surface of the lower jaw. Several dental implants are visible in the posterior region of the upper jaw. **Idiopathic** **Bone islands** are also considered as harmartomas Localised dense bone (often homogenous cortical density) Can occur anywhere Most common site: **MD premolar-molar region** Various morphologies *Seldom resorb teeth* Bone islands continuous with cortical plates are termed enostosis Further evaluation not required. Monitor with I/O or OPG (unless symptomatic)  - Bone islands are also considered as hamartomas. - Localised dense bone (often homogeneous cortical density). - Can occur anywhere. - Most common site: mandibular premolar-molar region. - Various morphologies. - Seldom resorb teeth. - Bone islands continuous with cortical plates are termed enostosis. - Further evaluation not required. - Monitor with I/O or OPG (unless symptomatic). A composite medical image containing six radiographic panels labeled A through F demonstrating 'Bone islands' (enostosis). The text on the left describes these as localized dense bone lesions, often homogenous and cortical in density, found in the mandible (MD) premolar-molar region. Panel A shows a periapical view of teeth with a small radiopaque lesion in the alveolar bone. Panel B displays a similar finding adjacent to tooth roots. Panel C presents another periapical view showing a well-defined radiopacity. Panel D is a panoramic radiograph (OPG) revealing a larger, dense radiopaque mass in the mandibular body near the molar region. Panels E and F are axial and sagittal CT slices respectively, illustrating the continuity of the bone island with the surrounding cortical plates, consistent with the definition of enostosis provided in the text. - **Florid COD** Multifocal COD involving 2 or more quadrants - **Periapical COD** - Can consider **CBCT** review - **Cemento-osseous Dysplasia** (unifocal or multifocal) - Early, immature lesions are **lucent** - Late, mature lesions are **opaque** with a **lucent rim** and **sclerotic borders** **Fibro-osseous**   - **Florid COD**: Multifocal COD involving 2 or more quadrants - **Periapical COD** - Can consider CBCT review - **Cemento-osseous Dysplasia** (unifocal or multifocal) - Early, immature lesions are lucent - Late, mature lesions are opaque with a lucent rim and sclerotic borders - Fibro-osseous Panoramic radiograph showing a large, mixed-density radiopaque lesion in the mandible. The caption identifies this as 'Florid COD' (Cemento-osseous Dysplasia), noting it is multifocal and involves two or more quadrants. A composite figure containing four periapical radiographs labeled A and B. These images show early-stage Cemento-osseous Dysplasia lesions appearing as radiolucent areas at the apices of the teeth. <ul> <li>Fibro-osseous</li> <li>Fibrous Dysplasia</li> </ul> <p>Classic ground-glass appearance</p> <p>Smooth expansion</p> <p>Heterogenous pattern; mixed hypodensity & ground-glass bone</p> <p>CBCT vs MDCT</p>    - Fibro-osseous - Fibrous Dysplasia - Classic ground-glass appearance - Smooth expansion - Heterogenous pattern; mixed hypodensity & ground-glass bone - CBCT vs MDCT Coronal CBCT scan of the maxillofacial region showing a fibro-osseous lesion. The image displays a heterogenous pattern with areas of mixed hypodensity and ground-glass bone density, indicated by a black arrow pointing to the left side of the maxilla. Lateral panoramic radiograph (MDCT) demonstrating classic ground-glass appearance of fibrous dysplasia in the mandible, as indicated by white arrows. Two cropped views of dental radiographs showing smooth expansion of the alveolar bone, likely due to the underlying fibro-osseous lesion. # Malignancy>Ill-defined borders, fast-growing, destructive, invasive (invade through path of least resistance)>A**B**C**D>Cortical destruction> + various periosteal reaction>E1 **E2** E3 **E4**>“floating teeth"> - Loss of lamina dura>F**U**rgent Referral to Surgeon  - Ill-defined borders, fast-growing, destructive, invasive (invade through path of least resistance) - Cortical destruction + various periosteal reaction - "Floating teeth" - loss of lamina dura - **Urgent Referral to Surgeon** Composite medical diagram illustrating radiographic features of malignancy in the jaw. The figure contains six panels labeled A through F demonstrating different pathological signs: Panels A-D show cross-sections of teeth with ill-defined lesions; Panels E1-E4 display cortical destruction and various periosteal reactions; Panel F depicts 'floating teeth' due to loss of lamina dura. **Squamous cell carcinoma (left mx sinus)** **REFER to OMF Surgeons Straight Away** **Urgent Referral**  - Squamous cell carcinoma (left maxillary sinus) - Refer to OMF Surgeons straight away - Urgent Referral Radiograph showing a clinical case of squamous cell carcinoma in the left maxillary sinus. The image displays dental structures and the maxillary sinuses, with a notable abnormality or lesion indicated in the left region. The text emphasizes urgent referral to OMF surgeons for further evaluation.  Radiograph of the mandible showing a soft tissue mass invading into the mandible (MD). The image includes labels indicating 'Primarily soft tissue – invading into MD' and 'Urgent Referral'. **Osteoblastic Cancer** Metastatic cancer – primary prostate cancer **(some breast cancer also)** **Urgent Referral**  - Osteoblastic Cancer - Metastatic cancer – primary prostate cancer (some breast cancer also) - Urgent Referral Composite medical radiograph showing osteoblastic cancer metastasis. Panel A displays ill-defined borders (indicated by double arrows) in the mandible. Panel B shows a periosteal reaction forming a 'sunray' pattern (white arrows). Panels C and D illustrate loss of lamina dura around tooth roots. # Primary Bone Cancer ## Osteogenic sarcoma Urgent Referral      - Primary Bone Cancer: Osteogenic sarcoma - Urgent Referral Labelled radiograph showing a region of the mandible with two black arrows pointing to areas of bone destruction or irregularity associated with osteogenic sarcoma. Radiograph of anterior teeth with two black arrows indicating abnormal radiolucency or structural changes in the surrounding bone, consistent with primary bone cancer findings. Radiographic image displaying multiple teeth with an extensive area of radiopacity and possible bone involvement, labeled 'A', suggesting pathological changes related to osteogenic sarcoma. Cross-sectional imaging (possibly CT or MRI) showing detailed internal structure of a tooth and surrounding tissue, labeled 'B', highlighting potential abnormalities such as bone erosion or tumor presence. Coronal CT scan slice of the maxillofacial region showing anatomical structures including nasal cavity, sinuses, and jawbones. White arrows point to specific areas of interest, possibly indicating lesions or abnormalities associated with osteogenic sarcoma. # OPG Report Checklist 1. Identify any **significant OPG error** 2. Check stage of dentition (deciduous / mixed / permanent) 3. Identify any missing teeth (& supernumerary teeth, if present) * Are there implants in edentulous sites? * Comment on peri-implant crestal bone level. * Are there root remnants? 4. Identify any impacted or ectopic teeth * Location * Angulation * Morphology (both crown & root system) * Relationship with adjacent structures eg. Adjacent molars, mx sinus, IDC, etc. 5. Any dental anomalies? (eg. Dens invaginatus, supernumeraries, etc) 6. Identify periodontal bone loss * Perio-endo bony defects * Horizontal bone loss * Angular bony defects / vertical bone loss * Furcation involvement 7. Are there calculus deposits? Where? 8. Is there existing restorative therapy? * Identify any faulty restorations eg. overhang, insufficient margin 9. Identify caries including recurrent caries 10. Identify non-carious tooth loss (NCTL) eg. attrition 11. Is there existing endodontic therapy? 12. Identify periapical lucencies ie. periapical inflammatory lesions * Any associated root resorption, antral floor remodelling, reactive sclerosis, reactive mucosal thickening in antrum? 13. Identify any **abnormal lucencies or opacities** in the jaws * Location * Border and Morphology * Well-defined? Ill-defined? * Overall shape – oval, round, elongated, etc. * Internal architecture * Effects on adjacent structures * Surgical Sieve - Differential diagnoses if can. 14. Extragnathic structures * Maxillary sinuses – Symmetrical? Size? Opacity? Floor and walls intact? * Condyles – Symmetrical? Deformity? Remodelling? Sclerosis? Pitting? Beaking / lipping? Loose bodies? * Airspace * Cervical spine * Any presence of soft tissue calcifications? * Check submandibular region, tonsillar regions, carotid bulb region, etc. * Pterygomaxillary fissure * Orbits 15. Summary (for long reports or reports with significant pathology) * Further imaging required? If yes, which modality? 1. Identify any **significant OPG error** 2. Check stage of dentition (deciduous / mixed / permanent) 3. Identify any missing teeth (& supernumerary teeth, if present) - Are there implants in edentulous sites? - Comment on peri-implant crestal bone level. - Are there root remnants? 4. Identify any impacted or ectopic teeth - Location - Angulation - Morphology (both crown & root system) - Relationship with adjacent structures eg. Adjacent molars, mx sinus, IDC, etc. 5. Any dental anomalies? (eg. Dens invaginatus, supernumeraries, etc) 6. Identify periodontal bone loss - Perio-endo bony defects - Horizontal bone loss - Angular bony defects / vertical bone loss - Furcation involvement 7. Are there calculus deposits? Where? 8. Is there existing restorative therapy? - Identify any faulty restorations eg. overhang, insufficient margin 9. Identify caries including recurrent caries 10. Identify non-carious tooth loss (NCTL) eg. attrition 11. Is there existing endodontic therapy? 12. Identify periapical lucencies ie. periapical inflammatory lesions - Any associated root resorption, antral floor remodelling, reactive sclerosis, reactive mucosal thickening in antrum? 13. Identify any **abnormal lucencies or opacities** in the jaws - Location - Border and Morphology - Well-defined? Ill-defined? - Overall shape – oval, round, elongated, etc. - Internal architecture - Effects on adjacent structures - Surgical Sieve - Differential diagnoses if can. 14. Extragnathic structures - Maxillary sinuses – Symmetrical? Size? Opacity? Floor and walls intact? - Condyles – Symmetrical? Deformity? Remodelling? Sclerosis? Pitting? Beaking / lipping? Loose bodies? - Airspace - Cervical spine - Any presence of soft tissue calcifications? - Check submandibular region, tonsillar regions, carotid bulb region, etc. - Pterygomaxillary fissure - Orbits 15. Summary (for long reports or reports with significant pathology) - Further imaging required? If yes, which modality? # Further Reading Essentials of dental radiography and radiology 5th edition by Whaites, Eric; Drage, Nicholas White and Pharoah’s Oral radiology: principles and interpretation 8th edition By Ernest Lam Atlas of Oral and Maxillofacial Radiology By Bernard Koong - Essentials of dental radiography and radiology 5th edition by Whaites, Eric; Drage, Nicholas - White and Pharoah’s Oral radiology: principles and interpretation 8th edition By Ernest Lam - Atlas of Oral and Maxillofacial Radiology By Bernard Koong [^1]: Original PDF page 1: [[L13PR2.pdf#page=1|L13PR2, p.1]] [^2]: Original PDF page 2: [[L13PR2.pdf#page=2|L13PR2, p.2]] [^3]: Original PDF page 3: [[L13PR2.pdf#page=3|L13PR2, p.3]] [^4]: Original PDF page 4: [[L13PR2.pdf#page=4|L13PR2, p.4]] [^5]: Original PDF page 5: [[L13PR2.pdf#page=5|L13PR2, p.5]] [^6]: Original PDF page 6: [[L13PR2.pdf#page=6|L13PR2, p.6]] [^7]: Original PDF page 7: [[L13PR2.pdf#page=7|L13PR2, p.7]] [^8]: Original PDF page 8: [[L13PR2.pdf#page=8|L13PR2, p.8]] [^9]: Original PDF page 9: [[L13PR2.pdf#page=9|L13PR2, p.9]] [^10]: Original PDF page 10: [[L13PR2.pdf#page=10|L13PR2, p.10]] [^11]: Original PDF page 11: [[L13PR2.pdf#page=11|L13PR2, p.11]] [^12]: Original PDF page 12: [[L13PR2.pdf#page=12|L13PR2, p.12]] [^13]: Original PDF page 13: [[L13PR2.pdf#page=13|L13PR2, p.13]] [^14]: Original PDF page 14: [[L13PR2.pdf#page=14|L13PR2, p.14]] [^15]: Original PDF page 15: [[L13PR2.pdf#page=15|L13PR2, p.15]] [^16]: Original PDF page 16: [[L13PR2.pdf#page=16|L13PR2, p.16]] [^17]: Original PDF page 17: [[L13PR2.pdf#page=17|L13PR2, p.17]] [^18]: Original PDF page 18: [[L13PR2.pdf#page=18|L13PR2, p.18]] [^19]: Original PDF page 19: [[L13PR2.pdf#page=19|L13PR2, p.19]] [^20]: Original PDF page 20: [[L13PR2.pdf#page=20|L13PR2, p.20]] [^21]: Original PDF page 21: [[L13PR2.pdf#page=21|L13PR2, p.21]] [^22]: Original PDF page 22: [[L13PR2.pdf#page=22|L13PR2, p.22]] [^23]: Original PDF page 23: [[L13PR2.pdf#page=23|L13PR2, p.23]] [^24]: Original PDF page 24: [[L13PR2.pdf#page=24|L13PR2, p.24]] [^25]: Original PDF page 25: [[L13PR2.pdf#page=25|L13PR2, p.25]] [^26]: Original PDF page 26: [[L13PR2.pdf#page=26|L13PR2, p.26]] [^27]: Original PDF page 27: [[L13PR2.pdf#page=27|L13PR2, p.27]] [^28]: Original PDF page 28: [[L13PR2.pdf#page=28|L13PR2, p.28]] [^29]: Original PDF page 29: [[L13PR2.pdf#page=29|L13PR2, p.29]] [^30]: Original PDF page 30: [[L13PR2.pdf#page=30|L13PR2, p.30]] [^31]: Original PDF page 31: [[L13PR2.pdf#page=31|L13PR2, p.31]] [^32]: Original PDF page 32: [[L13PR2.pdf#page=32|L13PR2, p.32]] [^33]: Original PDF page 33: [[L13PR2.pdf#page=33|L13PR2, p.33]] [^34]: Original PDF page 34: [[L13PR2.pdf#page=34|L13PR2, p.34]]