You may remember from the last lecture… Systematic Approach * Step 1. Teeth & Surrounding Structures * Count teeth * Tooth morphology * Crown – enamel, dentine, pulp chamber, etc. * Roots – PDL space, lamina dura, # of roots, root morphology * Periodontal bone * Other * Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy * Assess restorative margins – presence of overhangs? Insufficient margins? * Presence of voids? * Step 3. Identify & describe abnormal radiolucencies & radiopacities * Location * Size & Extent * Morphology & Borders * Effects on surrounding structures * Internal architecture * Step 4. Differential diagnosis - **Step 1. Teeth & Surrounding Structures** - Count teeth - Tooth morphology - Crown – enamel, dentine, pulp chamber, etc. - Roots – PDL space, lamina dura, # of roots, root morphology - Periodontal bone - Other - **Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy** - Assess restorative margins – presence of overhangs? Insufficient margins? - Presence of voids? - **Step 3. Identify & describe abnormal radiolucencies & radiopacities** - Location - Size & Extent - Morphology & Borders - Effects on surrounding structures - Internal architecture - **Step 4. Differential diagnosis** You may remember from the last lecture... ## Systematic Approach * Step 1. Teeth & Surrounding Structures * Count teeth * Tooth morphology * Crown – enamel, dentine, pulp chamber, etc. * Roots – PDL space, lamina dura, # of roots, root morphology * Periodontal bone * Other - **Step 1. Teeth & Surrounding Structures** - Count teeth - Tooth morphology - Crown – enamel, dentine, pulp chamber, etc. - Roots – PDL space, lamina dura, # of roots, root morphology - Periodontal bone - Other **You may remember from the last lecture..** ## Systematic Approach * Step 1. Teeth & Surrounding Structures * Count teeth * Tooth morphology * Crown – enamel, dentine, pulp chamber, etc. * Roots – PDL space, lamina dura, # of roots, root morphology * Periodontal bone * Other * Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy * Assess restorative margins – presence of overhangs? Insufficient margins? * Presence of voids? - **Step 1. Teeth & Surrounding Structures** - Count teeth - Tooth morphology - Crown – enamel, dentine, pulp chamber, etc. - Roots – PDL space, lamina dura, # of roots, root morphology - Periodontal bone - Other - **Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy** - Assess restorative margins – presence of overhangs? Insufficient margins? - Presence of voids? You may remember from the last lecture... # Systematic Approach * Step 1. Teeth & Surrounding Structures * Count teeth * Tooth morphology * Crown – enamel, dentine, pulp chamber, etc. * Roots – PDL space, lamina dura, # of roots, root morphology * Periodontal bone * Other * Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy * Assess restorative margins – presence of overhangs? Insufficient margins? * Presence of voids? * Step 3. Identify & describe abnormal radiolucencies & radiopacities * Location * Size & Extent * Morphology & Borders * Effects on surrounding structures * Internal architecture    - **Step 1. Teeth & Surrounding Structures** - Count teeth - Tooth morphology - Crown – enamel, dentine, pulp chamber, etc. - Roots – PDL space, lamina dura, # of roots, root morphology - Periodontal bone - Other - **Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy** - Assess restorative margins – presence of overhangs? Insufficient margins? - Presence of voids? - **Step 3. Identify & describe abnormal radiolucencies & radiopacities** - Location - Size & Extent - Morphology & Borders - Effects on surrounding structures - Internal architecture A simple line drawing of a smiley face with closed eyes and a curved mouth, representing a positive or neutral state. A line drawing of a smiley face with open eyes and an open-mouthed grin, representing a happy state. A line drawing of a smiley face with open eyes and gritted teeth, representing pain or distress. **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 * Sclerotic * 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 **STEP 5: FORMULATE INTERPRETATION** **Further Reading:** **<bold>White & Pharoah's Oral Radiology 8th Ed (Chapter 18)</bold>**  **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 - Sclerotic - 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 **STEP 5: FORMULATE INTERPRETATION** **Further Reading:** White & Pharoah's Oral Radiology 8th Ed (Chapter 18) A structured procedural guide titled 'Analysis of Intraosseous Lesions' presented as a vertical list. It details five steps: Step 1 (Localize Abnormality), Step 2 (Assess Periphery and Shape - subdivided into Periphery and Shape characteristics), Step 3 (Analyze Internal Structure), Step 4 (Analyze Effects of Lesion on Surrounding Structures), and Step 5 (Formulate Interpretation). The text is formatted with bold headings and bullet points. You may remember from the last lecture… # Systematic Approach - Step 1. Teeth & Surrounding Structures - Count teeth - Tooth morphology - Crown – enamel, dentine, pulp chamber, etc. - Roots – PDL space, lamina dura, # of roots, root morphology - Periodontal bone - Other - Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy - Assess restorative margins – presence of overhangs? Insufficient margins? - Presence of voids? - Step 3. Identify & describe abnormal radiolucencies & radiopacities - Location - Size & Extent - Morphology & Borders - Effects on surrounding structures - Internal architecture - Step 4. Differential diagnosis  - **Step 1. Teeth & Surrounding Structures** - Count teeth - Tooth morphology - Crown – enamel, dentine, pulp chamber, etc. - Roots – PDL space, lamina dura, # of roots, root morphology - Periodontal bone - Other - **Step 2. Identify existing restorative therapy, endodontic therapy & orthodontic therapy** - Assess restorative margins – presence of overhangs? Insufficient margins? - Presence of voids? - **Step 3. Identify & describe abnormal radiolucencies & radiopacities** - Location - Size & Extent - Morphology & Borders - Effects on surrounding structures - Internal architecture - **Step 4. Differential diagnosis** A vertical column of four line-drawing smiley face icons used as visual markers for the steps listed in the text. From top to bottom: a standard neutral smile, a smiling face with an open mouth showing teeth, a grimacing or worried face with gritted teeth, and a frowning sad face. **5I 3-Scotland** Where "3-Scotland" relates to the three top killers in Scotland. •I: infection •I: inflammation •I: immune •I: iatrogenic •I: idiopathic •1: vascular/cardiovascular •2: cancer •3: trauma **Figure 17-26** Algorithm representing the diagnostic process that follows evaluation of the radiographic features of an abnormality. **VITAMIN C DEF** V - VASCULAR I - INFECTIVE/INFLAMMATORY T - TRAUMA A - AUTOIMMUNE M - METABOLIC I - IATROGENIC N - NEOPLASTIC C - CONGENITAL D - DEGENERATIVE E - ENDOCRINE/ENVIRONMENT F - FUNCTIONAL   **5I 3-Scotland** Where "3-Scotland" relates to the three top killers in Scotland. - I: infection - I: inflammation - I: immune - I: iatrogenic - I: idiopathic - 1: vascular/cardiovascular - 2: cancer - 3: trauma **Figure 17-26** Algorithm representing the diagnostic process that follows evaluation of the radiographic features of an abnormality. **VITAMIN C DEF** - V - VASCULAR - I - INFECTIVE/INFLAMMATORY - T - TRAUMA - A - AUTOIMMUNE - M - METABOLIC - I - IATROGENIC - N - NEOPLASTIC - C - CONGENITAL - D - DEGENERATIVE - E - ENDOCRINE/ENVIRONMENT - F - FUNCTIONAL Flowchart diagram illustrating a diagnostic algorithm starting with 'Image analysis algorithm' branching into 'Normal' and 'Abnormal'. The 'Abnormal' path further divides into 'Acquired' and 'Developmental'. Under 'Acquired', it branches into 'Cyst', 'Benign neoplasm', 'Malignant neoplasm', 'Bone dysplasia', 'Metabolic', 'Inflammatory', 'Vascular', and 'Trauma'. All nodes are color-coded rectangles. Mnemonic table titled 'VITAMIN C DEF' listing categories for differential diagnosis. Left column: V-VASCULAR, I-INFECTIVE/INFLAMMATORY, T-TRAUMA, A-AUTOIMMUNE, M-METABOLIC, I-IATROGENIC, N-NEOPLASTIC. Right column: C-CONGENITAL, D-DEGENERATIVE, E-ENDOCRINE/ENVIRONMENT, F-FUNCTIONAL. # General Cases This is a bite-wing radiograph, showing the Permanent Mandibular Right First Premolar and Second Premolar and Permanent Mandibular Left First Molar, Second Premolar, and First Molar. Normal Anatomy: This image displays a standard PA radiographic image. It shows the Permanent Mandibular Right Second Premolar (30), First Molar (31), and Permanent Mandibular Left Second Premolar (33), First Molar (32), and Second Molar number (37). The superimposition of the permanent Mandibular Left and Right Mentangles or canines in the deep Nazian fossa at the nasal root, intercalated by the coronoid process of the right mandible. These can be seen to be normal in all corners. There is: 1. Periodontal status? The periodontal status of the primary molar (20-30) appears normal, with no evidence of gingival or periodontal disease. The permanent Mandibular Right Second Premolar (30) and First Molar (31) and Permanent Mandibular Left Second Premolar (33), First Molar (32), and Second Molar (37) also appear normal, with no evidence of gingival or periodontal disease. 2. Restorations? The permanent Mandibular First Molar (32) has a large silver amalgam restoration in the occlusal area, with no further restorations visible on the periapical radiograph. 3. Caries? There is no radiographic evidence of caries in the permanent Mandibular Right Second Premolar (30) or First Molar (31) and Permanent Mandibular Left Second Premolar (33), First Molar (32), or Second Molar (37). 4. Resorption? There is no evidence of resorption in any of the teeth shown in the radiograph. 5. Periapical lesions? There is no evidence of periapical lesions around the roots of any of the teeth in the radiograph. 6. Other findings? The radiograph reveals the presence of a large silver amalgam restoration in the occlusal area of the permanent Mandibular First Molar (32). Additionally, there appears to be a small, well-defined radiolucency near the apices of the roots of the permanent Mandibular Third Molar (38), but it is not clear if the tooth is fully erupted or impacted.  This is a bite-wing radiograph, showing the Permanent Mandibular Right First Premolar and Second Premolar and Permanent Mandibular Left First Molar, Second Premolar, and First Molar. #### Normal Anatomy This image displays a standard PA radiographic image. It shows the Permanent Mandibular Right Second Premolar (30), First Molar (31), and Permanent Mandibular Left Second Premolar (33), First Molar (32), and Second Molar number (37). The superimposition of the permanent Mandibular Left and Right Mentangles or canines in the deep Nazian fossa at the nasal root, intercalated by the coronoid process of the right mandible. These can be seen to be normal in all corners. There is: 1. **Periodontal status?** The periodontal status of the primary molar (20-30) appears normal, with no evidence of gingival or periodontal disease. The permanent Mandibular Right Second Premolar (30) and First Molar (31) and Permanent Mandibular Left Second Premolar (33), First Molar (32), and Second Molar (37) also appear normal, with no evidence of gingival or periodontal disease. 2. **Restorations?** The permanent Mandibular First Molar (32) has a large silver amalgam restoration in the occlusal area, with no further restorations visible on the periapical radiograph. 3. **Caries?** There is no radiographic evidence of caries in the permanent Mandibular Right Second Premolar (30) or First Molar (31) and Permanent Mandibular Left Second Premolar (33), First Molar (32), or Second Molar (37). 4. **Resorption?** There is no evidence of resorption in any of the teeth shown in the radiograph. 5. **Periapical lesions?** There is no evidence of periapical lesions around the roots of any of the teeth in the radiograph. 6. **Other findings?** The radiograph reveals the presence of a large silver amalgam restoration in the occlusal area of the permanent Mandibular First Molar (32). Additionally, there appears to be a small, well-defined radiolucency near the apices of the roots of the permanent Mandibular Third Molar (38), but it is not clear if the tooth is fully erupted or impacted. Bite-wing radiograph showing the permanent mandibular right first premolar and second premolar and permanent mandibular left first molar, second premolar, and first molar. The image displays normal anatomy with no evidence of periodontal disease, caries, resorption, or periapical lesions. A large silver amalgam restoration is visible in the occlusal area of the permanent mandibular left first molar (32). This is a **bitewing radiograph**, showing the **maxillary posterior teeth (premolars and first molars)** and **mandibular posterior teeth (premolars and first molars)** from the right quadrant. **Identify the normal anatomy:** Alveolar bone crest, periodontal ligament space, lamina dura, enamel, dentin, and pulp chambers are visible. **There is:** 1. **Periodontal status:** Mild horizontal bone loss is evident, particularly around the mandibular premolars and the maxillary right canine (which appears to be the only non-molar tooth included in the field of view aside from premolars). The PDL space appears physiological. 2. **Restorations:** Multiple large, radiopaque restorations are visible, specifically in the maxillary right first and second premolars and the mandibular right first and second molars (or potentially first molar and canine depending on angulation). The **material** appears to be **amalgam** (metal). 3. **Caries:** There is evidence of **carious lesions** at the **occlusal surfaces of both mandibular premolars**, seen as radiolucent areas within the occlusal fossae. 4. **Resorption:** No obvious internal or external root resorption is identified. 5. **Periapical lesions:** None identified. 6. **Other findings:** The seeds or foreign material seen in the lower jaw area (superficial to the root of the mandibular right first molar) appear to be artifacts, possibly grain or debris, rather than pathological calcification. The borders of the smaller molar teeth in the background appear to be in close apposition.    This is a **bitewing radiograph**, showing the **maxillary posterior teeth (premolars and first molars)** and **mandibular posterior teeth (premolars and first molars)** from the right quadrant. #### Normal Anatomy Alveolar bone crest, periodontal ligament space, lamina dura, enamel, dentin, and pulp chambers are visible. There is: 1. **Periodontal status:** Mild horizontal bone loss is evident, particularly around the mandibular premolars and the maxillary right canine (which appears to be the only non-molar tooth included in the field of view aside from premolars). The PDL space appears physiological. 2. **Restorations:** Multiple large, radiopaque restorations are visible, specifically in the maxillary right first and second premolars and the mandibular right first and second molars (or potentially first molar and canine depending on angulation). The **material** appears to be **amalgam** (metal). 3. **Caries:** There is evidence of **carious lesions** at the **occlusal surfaces of both mandibular premolars**, seen as radiolucent areas within the occlusal fossae. 4. **Resorption:** No obvious internal or external root resorption is identified. 5. **Periapical lesions:** None identified. 6. **Other findings:** The seeds or foreign material seen in the lower jaw area (superficial to the root of the mandibular right first molar) appear to be artifacts, possibly grain or debris, rather than pathological calcification. The borders of the smaller molar teeth in the background appear to be in close apposition. Text box containing a structured list of questions for radiographic analysis: 'This is a <type of radiograph>, showing the <insert tooth numbers>. <Identify the normal anatomy> There is: 1. Periodontal status? 2. Restorations? (Bonus: material?) 3. Caries? 4. Resorption? 5. Periapical lesions? (not applicable for BW) 6. Other findings?' Bitewing radiograph showing maxillary and mandibular posterior teeth from the right quadrant. Visible features include multiple large radiopaque amalgam restorations in the maxillary premolars and mandibular molars. Mild horizontal bone loss is evident around the mandibular premolars. Radiolucent carious lesions are visible on the occlusal surfaces of the mandibular premolars. Bitewing radiograph showing maxillary and mandibular posterior teeth from the right quadrant. Multiple large radiopaque amalgam restorations are present in both arches. The alveolar bone crest shows mild horizontal resorption. No obvious periapical lesions or root resorption are identified. This is an intraoral periapical radiograph (IOPA), showing teeth 21, 22, 23, 24, and 34. <Identify the normal anatomy>. There is: 1. Periodontal status? 2. Restorations? (Bonus: material?) 3. Caries? 4. Resorption? 5. Periapical lesions? (not applicable for BW) 6. Other findings?  This is an intraoral periapical radiograph (IOPA), showing teeth 21, 22, 23, 24, and 34. <Identify the normal anatomy>. There is: 1. Periodontal status? 2. Restorations? (Bonus: material?) 3. Caries? 4. Resorption? 5. Periapical lesions? (not applicable for BW) 6. Other findings? Intraoral periapical radiograph (IOPA) showing the mandibular anterior teeth region. Visible teeth include 21, 22, 23, 24, and 34. Multiple restorations are present: a single amalgam restoration on tooth 21, multiple amalgam fillings on teeth 22 and 23, and extensive restorative work including amalgam and possibly crowns or large composite build-ups on teeth 24 and 34. The image demonstrates normal anatomical structures of the mandible and periodontal ligament spaces. This is a **type of radiograph**, showing the **insert tooth numbers**. <Identify the normal anatomy>. There is: 1. Periodontal status? 2. **Restorations**? (Bonus: material?) 3. Caries? 4. Resorption? 5. Periapical lesions? (not applicable for BW) 6. Other findings?  This is a **type of radiograph**, showing the **insert tooth numbers**. <Identify the normal anatomy>. There is: 1. Periodontal status? 2. **Restorations**? (Bonus: material?) 3. Caries? 4. Resorption? 5. Periapical lesions? (not applicable for BW) 6. Other findings? Clinical radiograph (periapical X-ray) of the anterior maxillary teeth. The image displays the central incisors, lateral incisors, and canines with associated periodontal bone levels. Notable findings include a large radiopaque restoration in the right canine and another restoration in the left lateral incisor. This is an intraoral periapical radiograph, showing the mandibular right incisors and canine (teeth #24, #25, #26, and the developing #27). There is: 1. Periodontal status? 2. Restorations? (Bonus: material?) 3. Caries? 4. Resorption? 5. Periapical lesions? (not applicable for BW) 6. Other findings?  This is an intraoral periapical radiograph, showing the mandibular right incisors and canine (teeth #24, #25, #26, and the developing #27). There is: 1. Periodontal status? 2. Restorations? (Bonus: material?) 3. Caries? 4. Resorption? 5. Periapical lesions? (not applicable for BW) 6. Other findings? Intraoral periapical radiograph showing the mandibular right incisors and canine (teeth #24, #25, #26, and developing #27). Visible anatomy includes crowns, roots, periodontal ligament spaces, lamina dura, and surrounding alveolar bone. The image displays normal anatomical structures without obvious pathology. This is an intraoral periapical radiograph, showing the teeth numbered 22, 23, 24, and 25. The image exhibits the following: 1. **Periodontal status**: There is generalized horizontal alveolar bone loss, with bone crest levels approximately 3-5mm below the CEJ. The right of the crest of the second molar (tooth #24) shows first-degree furcation involvement. 2. **Restorations**: There is evidence of a radiopaque restorative material (amalgam filling) in the right lingual portion of the right maxillary first premolar (#24). 3. **Caries**: No obvious signs of caries are detected. 4. **Resorption**: No signs of external or internal resorption. 5. **Periapical lesions**: No evidence of periapical radiolucencies. 6. **Other findings**: The right mandibular canine (#32) shows a significantly wider crown than the normal-root ratio, suggesting an anatomical variation or ectopic indentation.  This is an intraoral periapical radiograph, showing the teeth numbered 22, 23, 24, and 25. The image exhibits the following: 1. **Periodontal status**: There is generalized horizontal alveolar bone loss, with bone crest levels approximately 3-5mm below the CEJ. The right of the crest of the second molar (tooth #24) shows first-degree furcation involvement. 2. **Restorations**: There is evidence of a radiopaque restorative material (amalgam filling) in the right lingual portion of the right maxillary first premolar (#24). 3. **Caries**: No obvious signs of caries are detected. 4. **Resorption**: No signs of external or internal resorption. 5. **Periapical lesions**: No evidence of periapical radiolucencies. 6. **Other findings**: The right mandibular canine (#32) shows a significantly wider crown than the normal-root ratio, suggesting an anatomical variation or ectopic indentation. Radiograph: Intraoral periapical radiograph showing teeth numbered 22, 23, 24, and 25. The image exhibits generalized horizontal alveolar bone loss with bone crest levels approximately 3-5mm below the CEJ. There is evidence of a radiopaque restorative material (amalgam filling) in the right lingual portion of tooth #24. No obvious signs of caries or resorption are detected. The right mandibular canine (#32) shows a significantly wider crown than the normal-root ratio, suggesting an anatomical variation.     Intraoral periapical radiograph showing maxillary anterior teeth. A gutta-percha cone is visible within the periodontal ligament space of the central incisor, indicating a perforation or vertical root fracture. There is significant horizontal bone loss and widening of the PDL space. Clinical intraoral photograph of the gingival margin of a maxillary tooth. The tissue appears erythematous with a distinct sinus tract or draining fistula visible in the interdental papilla region. Clinical photograph demonstrating the use of a blue-tipped probe to locate a sinus tract opening on the gingiva between two anterior teeth. Illustration of a set of endodontic locating files (sinus tracers). The image displays multiple thin metal instruments with colored tips (white, yellow, red, blue, green, black) used for tracing sinus tracts. **ASA 202** — one endo smoke evacuation, dual angle    **ASA 202** — one endo smoke evacuation, dual angle Clinical radiograph showing a dental procedure with endodontic instruments and an ASA 202 dual-angle smoke evacuation tip positioned in the mouth. Product photograph of six ASA endo smoke evacuation tips arranged vertically. From top to bottom: white handle labeled '15', yellow handle labeled '20', red handle labeled '25', blue handle labeled '30', green handle labeled '35', and black handle labeled '40'. The tips are metal and helical in design. Product photograph of a metallic ASA 202 dual angle smoke evacuation device. The label 'ASA 202' is clearly visible on the upper curved section of the instrument. <table> <tr> <th>Image analysis algorithm</th> </tr> <tr> <td>Normal</td> <td>Abnormal</td> </tr> <tr> <td></td> <td>Developmental</td> </tr> <tr> <td>Acquired</td> <td></td> </tr> <tr> <td>Cyst</td> <td>Benign neoplasm</td> </tr> <tr> <td>Malignant neoplasm</td> <td>Inflammatory</td> </tr> <tr> <td>Bone dysplasia</td> <td>Vascular</td> </tr> <tr> <td>Metabolic</td> <td>Trauma</td> </tr> </table> **White and Pharoah's** **ORAL** **RADIOLOGY** *Principles and Interpretation* 8<sup>th</sup> **EDITION** ELSEVIER Sanjay M. **Mallya** Ernest W.N. **Lam** Further Reading: White & Pharoah’s Oral Radiology 8<sup>th</sup> Ed (Chapter 21)   | | | |---|---| | **Image analysis algorithm** | | | **Normal** | **Abnormal** | | | Developmental | | Acquired | | | Cyst | Benign neoplasm | | Malignant neoplasm | Inflammatory | | Bone dysplasia | Vascular | | Metabolic | Trauma | **White and Pharoah's** **ORAL** **RADIOLOGY** *Principles and Interpretation* 8th **EDITION** ELSEVIER Sanjay M. **Mallya** Ernest W.N. **Lam** Further Reading: White & Pharoah’s Oral Radiology 8th Ed (Chapter 21) Flowchart diagram showing the 'Image analysis algorithm' branching into 'Normal' and 'Abnormal'. The 'Abnormal' path splits into 'Acquired' and 'Developmental', with a blue arrow pointing to 'Developmental'. Under 'Acquired', subcategories include Cyst, Malignant neoplasm, Bone dysplasia, Metabolic (left column) and Benign neoplasm, Inflammatory, Vascular, Trauma (right column). Book cover for White and Pharoah's Oral Radiology 8th Edition, featuring three CT scan images of mandibles.   Radiograph showing multiple impacted teeth in the maxillary region. Clinical intraoral photograph of the upper jaw showing multiple supernumerary teeth and a small gingival swelling.   Clinical intraoral photograph of posterior teeth showing occlusal surfaces. A black arrow points to a specific anatomical feature or lesion on the central fissure of one molar tooth. Dental radiograph (periapical view) displaying the roots and crowns of posterior teeth in a dental arch. The image shows root structures, periodontal ligament spaces, and alveolar bone levels.   Clinical radiograph showing the maxillary anterior region. A large, well-defined radiolucent lesion is visible in the midline (intercanine region), extending from the crest of the alveolar bone to the floor of the nasal cavity. The lesion appears to be displacing adjacent teeth and may involve the incisive canal area. Gross pathology specimen photograph showing an extracted tooth with a distinct round, white, calcified mass attached to the cervical aspect of the root. This appearance is consistent with a cementoblastoma or similar odontogenic tumor. **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 * Sclerotic * Soft tissue capsule (**highlighted**) * Ill defined * Blending * Invasive **Shape** * Circular * Scalloped * Irregular STEP 3: ANALYZE INTERNAL STRUCTURE * Totally radiolucent * Totally radiopaque * Mixed (describe pattern) (**highlighted**) 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 STEP 5: FORMULATE INTERPRETATION   **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 - Sclerotic - Soft tissue capsule (**highlighted**) - Ill defined - Blending - Invasive **Shape** - Circular - Scalloped - Irregular **STEP 3: ANALYZE INTERNAL STRUCTURE** - Totally radiolucent - Totally radiopaque - Mixed (describe pattern) (**highlighted**) **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 **STEP 5: FORMULATE INTERPRETATION** Clinical dental radiograph (periapical view) of the anterior maxilla. The image displays a well-defined, mixed radiolucent-radiopaque lesion located in the region of the central and lateral incisors. Red arrows point to the internal trabecular pattern within the lesion and its periphery. A structured text table outlining a five-step analysis protocol for intraosseous lesions. Key visual features include highlighted text indicating specific criteria: 'Well defined' (Periphery), 'Soft tissue capsule', and 'Mixed (describe pattern)' (Internal Structure). Further Reading: DOI: **10.17096/jiufd.52886**     Further Reading: DOI: **10.17096/jiufd.52886** Radiograph showing a large radiolucent lesion in the maxillary anterior region with multiple radiopaque calcified masses. Close-up view of the upper right quadrant showing teeth and surrounding bone structure. Close-up view of the lower left quadrant showing teeth and surrounding bone structure. Lateral view of the mandible showing the relationship between the teeth and the ramus. Further Reading: DOI: **10.1186/1750-1172-2-17**   Further Reading: DOI: **10.1186/1750-1172-2-17** Dental radiograph showing a cross-sectional view of teeth. A dark horizontal rectangular object, likely an instrument or probe, is positioned between the upper and lower tooth rows. The image displays multiple teeth with visible enamel, dentin, and root structures. Second dental radiograph panel, adjacent to the first, displaying similar anatomical features including teeth and a horizontal dark object separating the occlusal planes. Both panels appear to be part of a comparative study on dental anatomy or pathology. Resorption **Further Reading:** Heithersay GS. Management of Tooth Resorption. Aust Dent J. 2007; 52:105-121 https://doi.org/10.1111/j.1834-7819.2007.tb00519.x #### Resorption **Further Reading:** Heithersay GS. Management of Tooth Resorption. Aust Dent J. 2007; 52:105-121 https://doi.org/10.1111/j.1834-7819.2007.tb00519.x  Dental radiograph showing anterior teeth with orthodontic brackets and a coiled wire visible at the bottom. The image captures the crowns and roots of multiple teeth, with one tooth appearing impacted or supernumerary above the others.  Radiograph showing a dental structure with visible root and surrounding bone. The image includes the label 'b' in the bottom left corner.  Radiograph showing multiple teeth in the dental arch with visible roots and crowns. <table> <tr> <td> </td> </tr> <tr> <td> </td> </tr> <tr> <td> </td> </tr> <tr> <td> </td> </tr> <tr> <td> </td> </tr> <tr> <td> </td> </tr> </table> **FIGURE 17-26** Algorithm representing the diagnostic process that follows evaluation of the radiographic features of an abnormality. Further Reading: 2020 IADT Guidelines for the Evaluation and Management of Traumatic Dental Injuries https://www.iadt-dentaltrauma.org/for-professionals.html  **FIGURE 17-26** Algorithm representing the diagnostic process that follows evaluation of the radiographic features of an abnormality. Further Reading: 2020 IADT Guidelines for the Evaluation and Management of Traumatic Dental Injuries https://www.iadt-dentaltrauma.org/for-professionals.html A hierarchical flowchart diagram illustrating a diagnostic algorithm. The process starts at the top with 'Image analysis algorithm', branching into 'Normal' and 'Abnormal'. The 'Abnormal' path splits further into 'Acquired' and 'Developmental'. Under 'Acquired', it branches into two columns: left column includes 'Cyst', 'Malignant neoplasm', 'Bone dysplasia', and 'Metabolic'; right column includes 'Benign neoplasm', 'Inflammatory', 'Vascular', and 'Trauma'. A large blue arrow points to the 'Trauma' box, highlighting its relevance.  Dental radiograph (periapical X-ray) of the maxillary anterior teeth. The image shows four central incisors and a canine. A white arrow points to the distal aspect of the right central incisor, highlighting a horizontal radiolucent line in the mid-root region, consistent with a vertical root fracture or a horizontal root resorption defect. **Von Arx & Bosshardt, 2016**  **Von Arx & Bosshardt, 2016** Radiograph showing multiple teeth with root canal treatments. The image displays several teeth with filled root canals, indicating endodontic therapy. The roots are clearly visible, and the fillings appear to extend close to the apices of the roots. The surrounding bone structure is also visible, providing context for the dental anatomy.  Clinical dental radiograph showing the maxillary anterior region. The image displays multiple teeth with visible root structures and surrounding alveolar bone. Notable findings include a radiolucent area (dark region) between the roots of adjacent teeth, suggestive of a periapical or interradicular pathology. The tooth on the right appears to have undergone endodontic treatment, as indicated by the presence of radiopaque material within the root canal spaces. The overall image quality is slightly grainy but provides sufficient detail for diagnostic interpretation. **Image analysis algorithm** **Normal** **Abnormal** **Acquired Cyst** **Malignant neoplasm** **Bone dysplasia** **Metabolic** **Benign neoplasm** **Inflammatory** **Vascular** **Trauma** **Developmental** White and Pharoah's **ORAL RADIOLOGY** Principles and Interpretation 8th EDITION Sanjay M. **Mallya** Ernest W.N. **Lam** ELSEVIER **Further Reading:** **White & Pharoah’s Oral Radiology 8th Ed** (Chapter 23)   #### Image analysis algorithm - **Normal** - **Abnormal** - Acquired Cyst - Malignant neoplasm - Bone dysplasia - Metabolic - Benign neoplasm - Inflammatory - Vascular - Trauma - Developmental White and Pharoah's **ORAL RADIOLOGY** Principles and Interpretation 8th EDITION Sanjay M. **Mallya** Ernest W.N. **Lam** ELSEVIER **Further Reading:** White & Pharoah's Oral Radiology 8th Ed (Chapter 23) A hierarchical flowchart diagram illustrating a diagnostic algorithm. The structure begins with 'Image analysis algorithm' at the top, branching into 'Normal' and 'Abnormal'. The 'Abnormal' path splits further into 'Acquired' and 'Developmental'. The 'Acquired' category branches out to eight specific conditions: Cyst, Benign neoplasm, Malignant neoplasm, Inflammatory, Bone dysplasia, Vascular, Metabolic, and Trauma. A blue arrow points towards the left side of the chart. The cover of the book 'White and Pharoah's ORAL RADIOLOGY Principles and Interpretation', 8th Edition, by Sanjay M. Mallya and Ernest W.N. Lam, published by Elsevier. The cover displays three distinct 3D CT renderings of human jawbones (mandibles) showing dental structures.   Dental radiograph showing multiple teeth in the mandibular arch. A well-defined, corticated, circular radiolucent lesion is visible between the roots of two central incisors. The surrounding bone appears sclerotic with a punched-out appearance. Adjacent teeth show normal root structure and periodontal ligament space. Structured table outlining a five-step approach to analyzing intraosseous lesions: Step 1 (Localize Abnormality), Step 2 (Assess Periphery and Shape), Step 3 (Analyze Internal Structure), Step 4 (Analyze Effects on Surrounding Structures), and Step 5 (Formulate Interpretation). Key diagnostic features such as 'corticated', 'sclerotic', 'punched-out', 'well defined', 'circular', and 'totally radiolucent' are highlighted in yellow for emphasis.   Dental radiograph showing multiple teeth with endodontic treatment (root canals) and restorations. A large radiolucent area is visible in the maxillary region, suggestive of a cyst or tumor. Dental radiograph showing anterior teeth with root canal treatments and restorations. The image provides a detailed view of the tooth structure and surrounding bone. Further Reading: http://dx.doi.org/10.1016/j.path.2016.10.006    Further Reading: http://dx.doi.org/10.1016/j.path.2016.10.006 A composite figure containing five distinct medical imaging panels arranged in a grid. The top row shows three sagittal CT scans of the maxilla revealing a radiolucent lesion involving tooth roots. The bottom row contains an axial CBCT slice showing the cross-section of the dental arch with the lesion, and a 3D volume-rendered reconstruction of the anterior facial skeleton highlighting the defect. A periapical dental radiograph (X-ray) displaying the upper anterior teeth. It reveals significant pathology in the central incisor region, characterized by large radiolucencies at the root apices and extensive internal resorption or structural loss within the tooth crowns. An orthopantomogram (OPG) or panoramic radiograph showing the full dentition. A large, well-defined radiolucent area is visible in the midline of the maxilla, extending across the nasal floor and sinus base, consistent with a cystic or tumorous lesion. | | | -------------------------- | | **Normal** | | **Abnormal** | | | | | **Cyst** | | | | | | **Maligant neoplasm** | | | | | | **Bone dysplasia** | | | | **Inflammatory** | | | | | **Metabolic** | | | | **Vascular** | | | | | **Trauma** | | < White and Pharoah's **ORAL RADIOLOGY** *Principles and Interpretation* 8<sup>th</sup> Edition Sanjay M. *Mallya* Ernest W.N. *Lam* ELSIEVIER Further Reading: White & Pharoah’s Oral Radiology 8<sup>th</sup> Ed (Chapter 25)   - Normal - Abnormal - Cyst - Maligant neoplasm - Bone dysplasia - Inflammatory - Metabolic - Vascular - Trauma White and Pharoah's **ORAL RADIOLOGY** *Principles and Interpretation* 8<sup>th</sup> Edition Sanjay M. *Mallya* Ernest W.N. *Lam* ELSIEVIER Further Reading: White & Pharoah’s Oral Radiology 8<sup>th</sup> Ed (Chapter 25) Flowchart diagram illustrating a diagnostic algorithm. It starts with 'Image analysis algorithm' branching into 'Normal' and 'Abnormal'. The 'Abnormal' path splits into 'Acquired' and 'Developmental'. Under 'Acquired', it further categorizes into: Cyst, Malignant neoplasm, Bone dysplasia (indicated by a large blue arrow), Metabolic, Benign neoplasm, Inflammatory, Vascular, Trauma. Book cover image for 'White and Pharoah's ORAL RADIOLOGY Principles and Interpretation 8th Edition' by Sanjay M. Mallya and Ernest W.N. Lam, published by Elsevier. The cover displays three small dental radiographs against a black background. ### 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 * Sclerotic * 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 **STEP 5: FORMULATE INTERPRETATION**  #### 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 - Sclerotic - 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 **STEP 5: FORMULATE INTERPRETATION** Clinical dental radiograph (periapical view) showing the maxillary anterior teeth. The image displays a distinct radiolucent lesion located at the root apex of the central incisor (middle tooth). This finding is pertinent to 'STEP 4: ANALYZE EFFECTS OF LESION ON SURROUNDING STRUCTURES' in the accompanying text, specifically regarding the assessment of the periodontal membrane space and lamina dura.    Radiograph showing the roots of three adjacent teeth with significant bone loss in the interproximal areas. Radiograph showing multiple teeth with a vertical probe or instrument placed between two central teeth. Radiograph showing four teeth with arrows pointing to specific features on the roots and surrounding bone structure.    Radiograph showing a close-up view of three adjacent teeth with significant periodontal bone loss and furcation involvement. The image is labeled 'B' in the bottom left corner. Wide-field radiograph of multiple anterior teeth showing extensive horizontal and vertical bone loss. A vertical line artifact runs through the center of the image. Close-up radiograph of anterior teeth with arrows pointing to specific areas of pathology. One arrow points to a region of bone loss between two teeth, while another arrow indicates a deeper defect or lesion at the base of the alveolar ridge. # Challenge Case ### Challenge Case Table 1: Figure 17-26 Algorithm representing the diagnostic process that follows evaluation of the radiographic features of an abnormality. | Image analysis algorithm | | :--- | | **Normal** | **Abnormal** | | | **Acquired** | **Developmental** | | | **Cyst** | **Benign neoplasm** | | | **Malignant neoplasm** | **Inflammatory** | | | **Bone dysplasia** | **Vascular** | | | **Metabolic** | **Trauma** | Table 2: Further Reading: http://dx.doi.org/10.1016/j.joms.2014.04.031   Table 1: Figure 17-26 Algorithm representing the diagnostic process that follows evaluation of the radiographic features of an abnormality. - **Normal** - **Abnormal** - **Acquired** - Cyst - Benign neoplasm - Malignant neoplasm - Bone dysplasia - Metabolic - **Developmental** - Inflammatory - Vascular - Trauma Further Reading: http://dx.doi.org/10.1016/j.joms.2014.04.031 Dental radiograph showing a section of the mandibular or maxillary arch with multiple teeth. The image displays tooth roots and surrounding alveolar bone structure. A darkened area is visible in the lower right quadrant, potentially indicating pathology such as a cyst, lesion, or periapical radiolucency. Flowchart diagram illustrating the diagnostic process following image analysis. The chart begins with 'Image analysis algorithm' branching into 'Normal' and 'Abnormal'. The 'Abnormal' path splits into 'Acquired' and 'Developmental'. Under 'Acquired', categories include Cyst, Malignant neoplasm, Bone dysplasia, Metabolic (left column) and Benign neoplasm, Inflammatory, Vascular, Trauma (right column). A large question mark appears to the right of the flowchart. Courtesy of Dr. Thomas Briggs         Courtesy of Dr. Thomas Briggs Clinical photo showing a close-up of the upper posterior teeth with significant plaque accumulation and gingival inflammation. Clinical photo showing the lower anterior teeth with heavy calculus deposits along the gumline and inflamed gingiva. Clinical photo showing the lower anterior teeth with generalized gingivitis and calculus buildup at the cervical margins. Photo of removed calculus deposits on a blue dental tissue, demonstrating the quantity of debris extracted during cleaning. Clinical photo showing the lower anterior teeth post-cleaning with some residual bleeding from the gums, indicating recent scaling or instrumentation. Clinical photo showing the upper posterior teeth with improved appearance after cleaning, though some staining remains. Clinical photo showing the lower anterior teeth with healthy pink gingiva and no visible calculus, representing a successful outcome of periodontal therapy. Clinical photo showing the upper posterior teeth with clean surfaces and healthy gingival tissues, demonstrating the results of professional cleaning.   Composite medical imaging figure showing multiple panels: top-left panel displays a cross-sectional view of an implant; top-middle panel shows two screws with a plate; top-right panels depict anatomical structures in grayscale. The image appears to be from a radiographic or CT scan study. Another composite medical imaging figure with three panels: left panel shows a detailed view of bone structure; middle panel depicts a circular object (possibly a joint or organ); right panel illustrates a tubular structure resembling intestines or blood vessels. All images are grayscale and appear to be from diagnostic scans. 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