abnormal calcifications in head n neck region including oral tissues like odontoma,aot,ceot,pulp stones,dentinal sclerosis

1. ABNORMAL CALCIFICATIONS IN
HEAD & NECK REGION (also
odontogenic orgins)
PREPARED BY : MUNAGA RAMAKRISHNA
GDCRI BALLARI
1

2. Table of contents
1.INTRODUCTION
2.CLASSIFICATION
A).DYSTROPHIC CALCIFICATION
• General Dystrophic calcification of oral regions
• Calcified lymph nodes
• Dystrophic calcifications in Tonsils
• Cysticercosis
• Arterial calcification
-a) Monck berg's Medial calcinosis
- Atherosclerotic Plaque
GDCRI BELLARY 2
B) IDIOPATHIC CALCIFICATION
• Sailolith
• Phleboliths
• Laryngeal cartilage calcification
• rhinolith or anthrolith.
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3. GDCRI BELLARY 3
• METASTATIC CALCIFICATION
• HETEROTROPIC CALCIFICATIONS
• ossification of stylohyoid ligament
• osteoma cutis
• myositis ossificans
1. localized(or) traumatic myositis ossificans
2. Progressive myositis ossificans
• CALCIFICATIONS IN ORAL TISSUES
• odontoma
• calcifying epithelial odontogenic tumor
• adenomatoid odontogenic tumor
• pulp stones (or) pulp calcifications
• dentinal sclerosis
• REFERENCES
PAGE NO
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4. ABNORMAL CALCIFICATIONS
GDCRI BELLARY 4

5. GDCRI BELLARY 5
CALCIFICATION :
• It is the accumulation of calcium salts in a body tissue, It
normally occurs in the formation of bone.
PATHOLOGIC CALCIFICATION:
•It is the abnormal tissue deposition of calcium salts,
together with smaller amounts of iron, magnesium and
other mineral salts.
CAUSES:
•Can be caused by vitamin k2 deficiency or by poor calcium
absorption due to a high calcium/vitamin D ratio.

6. GDCRI BELLARY 6
• HISTOPATHOLOGICAL STAINED SECTIONS
– Calcium salts appear as deeply basophilic, irregular
and granular
clumps.
– The deposits may be intracellular, extracellular, or at
both locations.
– Occasionally, hetero topic bone formation (ossification)
may occur.
– Calcium deposits can be confirmed by special stains
• Silver impregnation method of von-Kossa producing
black color,
• Alizarin red S that produces red staining.
– Pathologic calcification is often accompanied by diffuse
or granular
deposits of iron
• Positive Prussian blue reaction in Perl's stain

7. GDCRI BELLARY 7
A .Dystrophic Calcifications
• General dystrophic calcification of the oral regions
• Calcified lymph nodes
• Dystrophic calcification in the tonsils
• Cysticercosis
• Arterial calcification
- Moncke berg's medial calcinosis (Arteriosclerosis)
- Calcified Atherosclerotic plaque
B. Idiopathic calcifications
• Sailoliths
• Phleboliths
• Laryngeal cartilage calcifications
• Rhinolith/Antrolith
C. Metastatic calcifications
• Ossification of the stylohyoid ligament
• Osteoma cutis
* Myositis ossificans
-Localized(or) traumatic Myositis ossificans
- Progressive myositis ossificans
CLASSIFICATION

8. GDCRI BELLARY 8
•Dystrophic calcification is characterized by
deposition of calcium salts in dead and degenerated
tissues with normal calcium metabolism and normal
serum calcium levels.
• Pathogenesis:
• 2 Phases
• Initiation (nucleation)
• 2.Propagation – accumulation of Ca+2
phosphate salts
DYSTROPHIC CALCIFICATION

9. General dystrophic calcification of the oral regions
Dystrophic calcification is the precipitation of calcium salts
into primary sites of chronic inflammation or dead and dying
tissue.
clinical features:
Common sites: gingiva , tongue , lymph nodes, & cheek
• It is usually asymptomatic
• A solid mass of calcium salts sometimes can be palpated
Radiological features:
Fine grains of RADIO OPACITIES to large, irregular radiopaque
particles (<0.5CM)
The calcification may be homogeneous or may contain
punctuate areas
Irregular or indistinct outline
GDCRI BELLARY 9

10. GENERAL DYSTROPHIC CALCIFICATION OF THE ORAL REGIONS
GDCRI BELLARY 10

11. Calcified lymph nodes
• Dystrophic calcification occurs in lymph nodes that have been chronically
inflamed because of various diseases.
ARE:
• Tuberculosis(scrofula or cervical tuberculous lymphadenitis)
• Sarcoidosis
• Rheumatoid arthritis
• Systemic sclerosis
• Fungal infections
• Lymphoma
• Metastases from distant calcifying neoplasms
CLINICAL FEATURES
• Asymptomatic
• Sub mandibular, superficial and deep cervical lymphnodes
• NODES-bony hard , round or linear masses with variable mobility
GDCRI BELLARY 11

12. RADIOLOGICAL FEATURES
LOCATION :
• Submandibular
calcification may affect a single node or linear series of nodes in a
phenomenon known as lymph node “chaining”
PERIPHERY:
• Well defined , irregular occasionally having lobulated appearance
(cauliflower)
INTERNAL STRUCTURE:
• Without any pattern but may vary in the degree of radiopacity
• Egg shell calcification (Radio Opacities seen only on the surface of the node)
• DIFFERENTIAL DIAGNOSIS
GDCRI BELLARY 12
Sailolith-has a smooth outline .
Phlebolith- are small & multiple
Histo plasmosis -firm consistency
lymphoma –rubbery consistency

13. Calcified lymphnodes
GDCRI BELLARY 13

14. CALCIFIED LYMPHNODES RADIOGRAPHICAL VIEW
GDCRI BELLARY 14

15. Dystrophic calcification in the tonsils
Synonyms: Tonsillar calculi, Tonsillar concretions,
& tonsilloliths
• Tonsillar calculi are formed when repeated botus of
inflammation enlarge the tonsillar crypts
Clinical features:
• They present as hard , round , white or yellow objects
projecting from the tonsillar crypts
• Small calcifications are asymptomatic
• Large calcifications produce pain ,swelling, foetis oris,
dysphagia
• Older age groups are commonly
GDCRI BELLARY 15

16. RADIOLOGICAL FEATURES:
Location: Mid portion of the mandibular ramus
Tonsilliths frequently appear on the panoramic
radiograph immediately inferior to the mandibular
canal
Periphery: ill-defined
Internal structure: uniformly radiopaque
Differential diagnosis:
Calcified granulomatos disease-Firm
Syphilis-firm
Mycosis or lymphoma –firm
Radio opacity lesions such as dense bony islands
GDCRI BELLARY 16

17. DYSTROPHIC
CALCIFICATIONS OF TONSILS
GDCRI BELLARY 17

18. CYSTICERCOSIS
GDCRI BELLARY 18
Human ingests egg or gravid proglattids
The covering of the egg is digested
The larvae is hatched
It enters blood vessels and lymphatic's
Distributed in the tissues all over the body
In tissues other than intestinal mucosa the larvae eventually die
and are treated as foreign bodies causing grannuloma
formation scarring and calcification ,these areas in the tissues
are called cysticeri

19. GDCRI BELLARY 19

20. •CLINICAL FEATURES
•Mild cases are completely asymptomatic
•Moderate to severe cases have symptoms
range from mild to severe git upset
•Epi-gastric pain
•Severe nausea and vomiting
•Seizures, headache
•Visual disturbances
•Irritability.
GDCRI BELLARY 20

21. RADIOLOGICAL FEATURES:
• Location :
• Muscles of mastication and facial muscles and supra hyoid
muscles and post cervical musculature
• Periphery and shape:
• Multiple well defined elliptical Radio
opacity resembling grains of rice
• Internal structure: Homogeneously Radio opacity
• Differential diagnosis:
• Sailolith
• The small size of the calcified nodules of cysticerci and their
wide spread dissemination ,particularly in brain and muscle
are highly suggestive of the diagnosis
GDCRI BELLARY 21

22. CYSTICERCOSIS
GDCRI BELLARY 22

23. CYSTICERCOSIS
GDCRI BELLARY 23
Radiograph of a patient with cysticercosis. The calcified encysted larvae are
clearly seen in the soft tissues.
A single calcification in the area of the Wharton’s duct may be
easily mistaken for a sialolith on an intraoral film

24. ARTERIAL CALCIFICATION
Two distinct type of arterial calcification can
be identified both radiographically &
histologically
•A) Monckberg’s medial calcinosis
•B) Calcified atherosclerotic plaque
GDCRI BELLARY 24

25. MONCKBERG’S MEDIAL CALCINOSIS
Synonym: Arteriosclerosis
• Degeneration and eventual loss of elastic fibers followed by
the deposition of the calcium within the medial coat of
vessel.
Clinical features:
• Initially asymptomatic
• In later cases cutaneous gangrene peripheral vascular
disease and myositis.
• Patients with sturge -Weber syndrome also develop
intracranial arterial calcification
GDCRI BELLARY 25

26. Radiological features:
• Location : Facial artery .
less commonly carotid artery
• Periphery and shape:
• It outline an image of the artery ,appears as a parallel pair
of thin Radio opacity lines –pipe stem or tram track
appearance
• In cross section ,involved vessels will display a circular or
ring like pattern
Differential diagnosis:
• The radiographic appearance of arteriosclerosis is so
distinctive as to be pathognomic of the condition
• In addition hyper parathyroidsm may be considered as
medial calcinosis frequently develops as a metastatic
calcification in patients with this condition.
GDCRI BELLARY 26

27. Monckberg’s medial calcinosis
GDCRI BELLARY 27
Calcification of the facial artery. It may occur in arteriosclerosis

28. HISTOPATHOLOGY
• The calcifications can be seen in the tunica media in the PURPLISH BLUE.
• The lumen is un affected by this process.
• Destruction of muscle and elastic fibers and formation of calcium
deposits.
GDCRI BELLARY 28
Monckberg’s medial calcific sclerosis

29. CALCIFIED ATHEROSCLEROTIC PLAQUE
• Atheromatous plaque found in the extra cranial carotid
vasculature and is a major contributing source of cerebro
vascular embolic and occlusive disease.
• Dystrophic calcifications can occur in the evolution of plaque
within the intima of the involved vessel.
RADIOGRAPHIC FEATURES:
• These lesions may be visible on the panoramic radiograph in
the soft tissues of the neck adjacent to the greater cornu of the
hyoid bone and the cervical vertebrae C3, C4 or the
intervertebral space between them.
PERIPHERY & SHAPE: multiple and irregular in shape and sharply
defined from the surrounding tissues
INTERNAL STRUCTURE: heterogeneous radiopacity with
radiolucent voids
GDCRI BELLARY 29

30. Calcified atherosclerotic plaque
GDCRI BELLARY 30
Digital panoramic radiography with images suggesting the presence of atheroma
on both sides.

31. DIFFERENTIAL DIAGNOSIS
• Calcified triticeous cartilage may be mistaken for
atheromatous plaque, although the uniform size, shape and
location of calcified triticeous cartilage in the laryngeal
cartilage generally aids in identification of this condition.
• HISTOPATHOLOGY:
• Microscopically Atherosclerotic plaques three principle
components.
• 1)cells including smooth muscle cells, macrophages, and
other leucocytes.
• 2)extracellular matrix including collagen, elastic fibers, and
proteoglycans.
• 3)intracellular and extra cellular lipids.
• The calcification occurs in the tunica intima
GDCRI BELLARY 31

32. Atherosclerotic plaque
GDCRI BELLARY 32

33. IDIOPATHIC CALCIFICATIONS
• This results from deposition of calcium in normal tissue
despite normal serum calcium phosphate levels
• Sialoliths
• Phleboliths
• Laryngeal cartilage calcifications
• Rhinolith /Antrolith
GDCRI BELLARY 33

34. SIALOLITH
Sialolith are calcified deposits in the ducts of the major
salivary glands or within the glands themselves
• Etiology: It is believed that a nidus of salivary organic
material becomes calcified and gradually forms a sialolith
• The structure of sialoliths is crystalline
• 50% of parotid gland sialoliths and 20% of submandibular
gland sialoliths are poorly calcified. This is clinically
significant because such sialoliths are not radio graphically
detectable
GDCRI BELLARY 34

35. • The submandibular gland is the most common site of
involvement, 80 to 90%
• The parotid gland - 5 to 15%
• The sublingual gland or minor salivary glands- 2 to 5%
REASONS:
• The torturous course of Wharton’s duct
• Higher calcium and phosphate levels, and
• The dependent position of the submandibular glands,
which leave them prone to stasis.
GDCRI BELLARY 35

36. CLINICAL FEATURES:
• Present with a history of acute, painful, and
intermittent swelling of the affected major salivary
gland.
• Typically, eating will initiate the salivary gland
swelling.
• The involved gland is usually enlarged and tender
• The soft tissue surrounding the duct may show a
severe inflammatory reaction
• Complications: Acute sialadenitis,
Ductal stricture, and
Ductal dilatation
GDCRI BELLARY 36

37. GDCRI BELLARY 37

38. GDCRI BELLARY 38
RADIOLOGICAL FEATURE:
LOCATION: Sub mandibular gland ( 83 to 94 %)
50% lies in the distal portion of warthon’s duct
20% in the proximal portion ,
30% in the gland itself
PERIPHERY & SHAPE:
Duct-cylindric & very smooth in their outline
INTERNAL STRUCTURE:
Some stones are Homogeneously Radio opaque
Others show evidence of multiple layers of calcifications

39. GDCRI BELLARY 39
Occlusal view demonstrates a calcified deposit in Wharton’s duct.
Sialogram of the submandibular gland
SAILOLITH

40. INVESTIGATIONS
Submandibular duct:
• Periapical view
• Standard mandibular Occlusal view using half exposure time –
Distal part of Wharton's duct
• Lateral oblique or panoramic view –post part of duct
Parotid gland:
• Periapical RADIOGRAPH placed in the buccal vestibule & the
central x-ray directed through cheek
• AP. skull view
• Lateral skull projection.
• If non calcified stones are suspected SAILOGRAPHY is helpful
• CT scan
• MRI
• Radio nuclide salivary imaging
GDCRI BELLARY 40

41. DIFFERENTIAL DIAGNOSIS:
1) A calcified lymph node-Incidence
2) An avulsed or embedded tooth
3) A phlebolith –Symptoms of sailadentitis are
absent
4) Calcification in the facial Artery-serpentine
calcified image is diagnostic
5) Myositis ossificans-Restricted mandibular
movement
6) An anatomic structure such as hyoid bone-The
shape is significant & it is bilateral.
GDCRI BELLARY 41

42. PHLEBOLITHS
• Phleboliths are calcified thrombi found in veins, or the
sinusoidal vessels of hemangiomas .
clinical features:
• In head and neck , phlebolith nearly always signals the
presence of a hemangioma.
• Or it may be the sole residua of a childhood hemangioma.
• The involved soft tissue may be swollen, throbbing or
discolored by the presence of veins or a soft tissue
hemangioma.
GDCRI BELLARY 42

43. RADIOLOGICAL FEATURES:
Location: most commonly found in hemangiomas
Periphery & shape: In cross section the shape is round or oval
with a smooth periphery.
Internal structure: It may be homogeneously radiopaque but
more commonly has the appearance of laminations giving
a bull’s eye or target appearance ;a Radio Lucent centre
may be seen .
Differential Diagnosis:
• Sailolith
• Tonsilloliths
• Arterial calcifications.
• Myositis ossificans
• Cysticercosis
• Calcified acne – superficial lesions.
GDCRI BELLARY 43

44. GDCRI BELLARY 44
A case report of intramuscular hemangioma presenting with multiple
phleboliths
PHLEBOLITH

45. GDCRI BELLARY 45
Panoramic radiography with image suggesting multiple phleboliths on the right side.

46. LARYNGEAL CARTILAGE CALCIFICATIONS
•A small paired triticeous cartilageous are
found within the lateral thyrohyoid ligaments.
•Both the thyroid and triticeous cartilages
contains hyaline cartilage which has a
tendency to calcify with advancing age.
GDCRI BELLARY 46

47. RADIOLOGICAL FEATURES:
Location: located on lateral view within the pharyngeal air
space inferior to greater cornu of hyoid bone and
adjacent to superior border of c4
Periphery and shape:
It is well defined & smooth
Internal structure:
homogeneous RADIO OPAQUE
Differential diagnosis:
Calcified triticeous cartilage may be confused with calcified
atheromatous plaque in the carotid bifurcation .
GDCRI BELLARY 47

48. Laryngeal cartilage
calcifications
GDCRI BELLARY 48

49. GDCRI BELLARY 49
Digital panoramic radiography with image suggesting triticeous cartilage on both
sides (between the greater horn of the hyoid and superior horn of the thyroid
cartilage).

50. RHINOLITH( or) ANTROLITH
• Hard calcified bodies or stones that occur in the nose
(Rhinoliths) or the antrum of the maxillary sinus (Antroliths)
arise from the deposition of mineral salts such as calcium
phosphate, calcium carbonate, and magnesium around a
nidus
GDCRI BELLARY 50
Anthrolith Rhinolith
Endogenous Exogenous substance
Adult population Pediatric population

51. CLINICAL FEATURES:
• Unilateral, purulent, rhinorrhea, Sinusitis ,Headache, Epistaxis,
Anosomia, fever.
RADIOLOGICAL FEATURES:
PERIPHERY AND SHAPE:
• Stones have variety of shapes and sizes
INTERNAL STRUCTURE :
• may present as homogeneous or heterogeneous RADIO OPAQUE
DIFFERENTIAL DIAGNOSIS:
• Osteoma
• Complex Odontoma
• Matured cementoma
• Periapical condensing osteitis
• Palatine torus
• Impacted teeth
• Ala of the nose
GDCRI BELLARY 51
RADIO LUCENT borders

52. GDCRI BELLARY 52
PERIAPICAL RADIOGRAPH DEMONSTRATING ANTHROLITH

53. RHINOLITH
GDCRI BELLARY 53
Lateral occlusal film shows a anthrolith positioned above the floor
of the nose. B, Posterior-anterior skull film of the same case demonstrating
that the rhinolith is positioned within the nasal fossa
ANTHROLITH

54. Metastatic calcification
• It results when minerals precipitate into normal tissue
as a result of higher than normal serum levels of
calcium or phosphate.
• When the mineral is deposited in soft tissue as
organized , well formed bone, the process is known as
HETEROTOPIC OSSIFICATION.
GDCRI BELLARY 54

55. Heterotopic ossification:
•Ossification of the stylohyoid ligament
•Osteoma cutis
•Myositis ossificans
a) Localized(or) traumatic myositis ossificans
b) Progressive myositis ossificans.
GDCRI BALLARI

56. OSSIFICATION OF THE STYLOHYOID LIGAMENT
• Ossification of the stylohyoid ligament usually extends
downward from the base of the skull and commonly occurs
bilaterally
• However in rare cases the ossification begins at the lesser horn of
the hyoid and fewer still in a central area of the ligament.
CLINICAL FEATURES:
• Symptoms related to this ossified ligament are termed EAGLE
SYNDROME
CLASSIC EAGLE SYNDROME: cranial nerve impingement.
CAROTID ARTERY SYNDROME
• Intense pain in pharynx during swallowing & turning head or
opening the mouth especially on yawning.
GDCRI BELLARY 56

57. OSSIFICATION OF THE STYLOHYOID LIGAMENT
GDCRI BELLARY 57
Patient with Eagle’s syndrome. The stylohyoid ligaments are bilaterally calcified

58. Classification
BASED ON LANGLAIS& ASSOCIATES (1986)
• TYPE I : ELONGATED
• TYPE II: PSUEDO ARTICULATED
• TYPE III: SEGMENTED
GDCRI BELLARY 58

59. RADIOLOGICAL FEATURES
Location: The linear ossification extends forward from the
region of the mastoid process and crosses the posterio
inferior aspect of the ramus towards the hyoid bone
Shape: Appears as a long tapering thin Radio opaque
process .
• It normally varies from 0.5 to 2.5 cm in length.
Internal structure: homogenously Radio opaque
DIFFERENTIAL DIAGNOSIS:
• Tempero mandibular joint dysfunction.
GDCRI BELLARY 59

60. OSTEOMA CUTIS
• Rare soft tissue ossification in the skin
• 85% of the cases occur secondary to acne of long
duration developing in a scar or chronic inflammatory
dermatisis.
CLINICAL FEATURES:
• Face is the most common site
• Tongue is the most intra oral common site (osteoma
mucosae or osseous choristoma)
• Some patients develop numerous lesions (multiple
miliary osteoma cutis )
GDCRI BELLARY 60

61. OSTEOMA CUTIS
GDCRI BELLARY 61

62. Radiological features:
• Location: cheek & lip regions
• Periphery & shape: smoothly outlined RADIOPAQUE
washer shaped images ,single or multiple
RADIOPACITIES usually measuring 0.1 to 5cm
• Internal structure: homogeneously RADIO OPAQUE but
usually has a RADIO LUCENT centre ( donut appearance
)
Differential diagnosis:
• Myositis ossificans
• Calcinosis cutis
GDCRI BELLARY 62

63. GDCRI BELLARY 63
OSTEOMA CUTIS
Osteoma cutis seen as
faint radiopaque
calcification in the
cheek

64. histopathology
GDCRI BELLARY 64
Histologically these are seen as areas of dense viable bone in the dermis or
subcutaneous tissue.
They are occasionally found in diffuse scleroderma, replacing the altered collagen in
the dermis and subcutaneous septa.

65. MYOSITIS OSSIFICANS
• In myositis ossificans; fibrous tissue & heterotrophic bone
form within the interstitial tissue of muscle and associated
tendons and ligaments, there is Secondary destruction and
atrophy of the muscle occur as the fibrous tissue and bone
interdigitate and separate the muscle fibers.
Two forms:
• localized (Traumatic) myositis ossificans
• progressive myositis ossificans.
GDCRI BELLARY 65

66. Localized (traumatic)myositis ossificans
SYNONYM: post traumatic myositis ossificans,
solitary myositis
ETIOLOGY:
• acute or chronic trauma,
• heavy muscular strain.
• muscle injury from multiple injections.
CLINICAL FEATURES: YOUNG MEN
• The site of the precipitated trauma remains swollen, tender
and painful.
• The over lying skin may be red and inflamed.
• Opening of jaw may be difficult.
GDCRI BELLARY 66

67. Radiographic features
Location:
• masseter and sterno cledomastoid
• The anterior attachment of temporalis as well as the medial
pterygoid muscles are at high risk of injury on administration of
mandibular block.
Periphery and shape:
• periphery is more Radio opaque than the internal structure
• shape irregular oval – linear streaks (pseudotrabeculae)
Internal structure:
• 3rd or 4th week-faint RO
• 2months-a delicate or feathery internal structure develop
• 6months- it becomes denser and more defined
Differential diagnosis:
• Ossification of stylohyoid ligament
• Soft tissue calcifications
GDCRI BELLARY 67

68. MICRO DESCRIPTION
EARLY LESIONS(3 WEEKS)
• Inner cellular zone resembling nodular fasciitis with short
fascicles or haphazard fibroblasts that are uniform with faint
eosinophilic cytoplasm, tapering processes, vesicular or finely
granular nuclei and variable nucleoli, usually numerous
mitotic figures but none atypical:
• Stroma is vascular, myxoid or edematous with extravasated
red blood cells, fibrin, scattered inflammatory cells and
osteoclast like gaint cells.
• If highly cellular, may mimic sarcoma such as osteo sarcoma
• Intermediate zone has osteoblasts depositing woven bone,
and outer zone has mineralized trabaculae.
LATER: Bone matures with formation of marrow and
myofibroblasts are less prominent.
GDCRI BELLARY 68

69. HISTOPATHOLOGY
GDCRI BELLARY 69

70. Traumatic myositis ossificans
GDCRI BELLARY 70
Soft tissue ossification extending from the
coronoid process in a superior direction,
following the anatomy of the temporalis
muscle
A rare isolated unilateral
myositis ossificans traumatic

71. PROGRESSIVE MYOSITIS OSSIFICANS
• Rare hereditary disease with autosomal dominant
transmission
Clinical features
• Affects children before 6yrs of age
• Occasionally seen in infants
• Males are more affected
• Progressive formation of heterotrophic bone occurs within the
interstitial tissue of muscles tendons ligaments and fascia
• Stiffness & limitations of the motion of the neck , chest ,back &
extremities
• In advanced stages disease result in petrified man
DIFFERENTIAL DIAGNOSIS:
• Rheumatoid arthritis
• calcinosis .
GDCRI BELLARY 71

72. GDCRI BELLARY 72
MYOSITIS OSSIFICANS
Myositis ossificans seen as bilateral
linear calcifications of the
sternohyoid muscles
Excessive ossification temporalis and
masseter

73. PATHOLOGIC CALCIFICATION IN ORAL TISSUES
• ODONTOMA
* COMPOUND ODONTOMA
* COMPLEX ODONTOMA
• CALCIFYING EPITHELIAL ODONTOGENIC TUMOR (PINDBORG TUMOR)
• ADENOMATOID ODONTOGENIC TUMOR(AOT)
• PULP CALCIFICATIONS OR PULP STONES
• DENTINAL SCLEROSIS.
GDCRI BELLARY 73

74. ODONTOMA
Definition:
• Odontomes are a group of common hamartomatous odontogenic
lesions with limited growth potential capable of producing normal
appearing enamel, dentin, cementum and pulp etc in an
unorganized fashion.
Two types :
1) Complex odontome
2) Compound odontome
GDCRI BELLARY 74

75. 1)Complex odontome:
• It consists of a completely disorganized and diffuse mass of
odontogenic tissue with haphazardly arranged enamel, dentin and
cementum.
2)Compound odontome:
• Compound odontome presents collections of numerous small,
discrete, tooth-like structures
• Most odontogenic tissues in compound odontome bear superficial
anatomical resemblance to normal teeth.
GDCRI BELLARY 75

76. Clinical features:
FREQUENCY:
• Represent about 7% of all odontogenic neoplasms
AGE:
• They occur in young age group, with the average age being second
decade of life.
SEX:
• There is no sex prediction.
LOCATION:
Compound : More often in the anterior maxilla
Complex: More often in the posterior mandible
GDCRI BELLARY 76

77. CLINICAL PRESENTATION
• Odontomes generally produce small, asymptomatic lesions which
are detected incidentally.
• Lesions vary in size greatly.
• May produce large, bony hard swellings of the jaw with, expansions
of cortical plates and displacement of regional teeth.
• A tooth may be often missing from the dental arch as the odontome
can block the eruption of the tooth.
GDCRI BELLARY 77

78. CLINICAL PRESENTATION
COMPUND
GDCRI BELLARY 78
COMPLEX

79. Radiological features:
• Odontomes usually produce pericoronal radiolucencies with well
corticated borders.
• A developing odontome may look completely radiolucent as the
calcified elements do not form in the initial stages.
COMPOUND ODONTOME:
• Radio graphically appear as numerous, small, miniature teeth or
tooth like structures, which are projecting from a single focus.
• apparently they look like “a bag of tooth” and are commonly
located between the roots of the erupted permanent teeth or
above the crown of an impacted tooth.
GDCRI BELLARY 79
THE COMPLEX ODONTOME:
• The complex odontomes radio graphically appears as
round or oval or “ sun burst like” conglomerated radio
opaque mass within the jaw bone

80. Radiological appearance
COMPUND
GDCRI BELLARY 80
COMPLEX

81. DIFFERENTIAL DIAGNOSIS:
• Calcifying epithelial odontogenic tumor(ceot)
• Ameloblastic fibrodentinoma
• Ameloblastic fibro- odontome
• Osteoma
• Odonto ameloblastoma
• Focal sclerosing osteo myelitis.
GDCRI BELLARY 81

82. HISTOPATHOLOGY
COMPOUND ODONTOME:
• Histologically compound odontome presents as encapsulated mass
of multiple separate denticles, embedded in a fibrous tissue stroma.
• However in each one of them, there is presence of enamel, dentin,
cementum and pulp tissues ,which are in a similar fashion as seen
as in a normal tooth
GDCRI BELLARY 82
COMPLEX ODONTOME:
• Histologically complex odontoma presents an irregularly arranged mass
of well framed enamel, dentin, cementum and pulp which is surrounded
by a fibrous capsule.
• Small islands of eosinophilic stained epithelial GHOST CELLS are
present.
• These may represent remnants of odontogenic epithelium that have
undergone keratinization and cell death from the local anoxia.

83. COMPOUND
GDCRI BELLARY 83
COMPLEX

84. Calcifying epithelial odontogenic tumor(ceot)
SYNONYMS:
• Pindborg’s tumor.
ORIGIN:
• The lesion arises from either the cells of the stratum intermedium of
the enamel organ or the reduced enamel epithelium or even the
remnants of the dental lamina.
• Difference to the ameloblastoma and ceot is calcifying epithelial
odontogenic tumor always contains some calcified materials within
it’s mass, which never seen in ameloblastoma.
GDCRI BELLARY 84

85. CLINICAL FEATURES:
INCIDENCE RATE:
About 1% of all odontogenic neoplasms.
Age:
middle aged(40) years more affected.
Sex:
• no sex differentiation.
Site:
• The mandible is more often involved than the maxilla.
• The molar region is the most common site of occurrence
followed by premolar region.
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86. CLINICAL SIGNIFICANCE:
Usually a slow enlarging, painless swelling of the jaw with expansion and
distortion of the cortical plates.
Displacement of regional teeth, with de-arrangement of occlusion and facial
asymmetry.
Large maxillary lesions may invade into the antrum or nasal floor and such
lesions occasionally cause nasal airway obstruction, epistaxis and proptosis of
the eyeball, etc.
GDCRI BELLARY 86

87. RADIOGRAPHICAL PRESENATATION
GDCRI BELLARY 87
Well defined, multilocular( rarely unilocular) radiolucent area in the jaw.
Calcifications within the tumor is a characteristic in the calcifying epithelial
odontogenic tumors and radio graphically it often exhibits multiple, small,
radiopaque foci varying radio density with the radiolucent zone produced.
Driven snow appearance. This type x-ray of calcification within the tumor often
produces a typical driven snow appearance

88. HISTOPATHOLOGY
• Histologically the tumor reveals SHEETS or ISLANDS of closely packed,
POLYHEDRAL EPITHELIAL CELLS in a non inflammed connective tissue
stroma.
• Sometimes the neoplastic cells may have a CRIBRIFORM arrangement
and they enclose areas of hyalinized stroma.
• Some amount of homogenous, hyaline materials is often deposited in
between the tumor cells, which stain like “AMYLOIDS”
• One of the most distinctive histological characteristics of ceot is the
presence of SEVERAL CALCIFIED BODIES OR MASSES within the lesion.
• These calcified masses are hematoxyphilic in nature and are present as
concentrically laminated rings LIESEGANG RINGS in and around the
degenerating tumor cells.
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89. Histopathology
GDCRI BELLARY 89

90. Differential diagnosis:
• Calcifying epithelial odontogenic cyst.
• Adenomatoid odontogenic tumor.
• Poorly differentiated carcinoma.
• Ameloblastoma.
• Ameloblastic fibro-odontoma.
• Dentigerous cyst.
• Central ossifying or cementifying fibroma.
GDCRI BELLARY 90

91. Adenomatoid odontogenic tumor(aot)
• The adenomatoid odontogenic tumor is a relatively uncommon,
well circumscribed, odontogenic neoplasm characterized by
the formations of multiple “duct-like” structures by the
neoplastic epithelial cells.
ORIGIN:
• Arises from the reduced enamel epithelium during the pre
secretory phase of enamel organ development.
GDCRI BELLARY 91

92. CLINICAL FEATURES
AGE:
• Younger age – 2nd and 3rd decade of life.
SEX:
• Females are more commonly affected in comparison to the males 2:1 ratio.
SITE:
• Typically occurs in the maxillary anterior region, sometimes in premolar
region.
• Rarely involves the angle-ramus area
• 70% of cases are in erupted tooth.
• CLINICAL PRESENTATION:
GDCRI BELLARY 92
• Slow ,enlarging, small, bony hard swelling in the maxillary anterior
region.
• Displacement of the regional teeth, mild pain and expansion of the
cortical bones are usually present.
• The extra osseous or peripheral tumor produces a solitary painless,
asymptomatic nodular swelling on the gingiva predominantly on
facial surface.

93. RADIOLOGICAL FEATURES
• A well circumscribed, unilocular, radiolucent area, which often
encloses a tooth or tooth like structure.
• Multiple small, radio opaque foci of varying radio density may be
present inside the lesion and finding is known as “ snow flake”
calcifications.
DIFFERENTIAL DIAGNOSIS:
• Dentigerous cyst
• Globulo maxillary cyst
• Lateral periodontal cyst
• Odontome
• Unicystic ameloblastoma
• Ossifying (or) cementifying fibroma
• Calcifying epithelial odontogenic tumor (or) cyst.
GDCRI BELLARY 93

94. radiographic and gross appearance
GDCRI BELLARY 94

95. HISTOPATHOLOGY
• Reveals spindle shaped, neoplastic odontogenic epithelial cells
proliferating in multiple “duct like” patterns, within a thin but
well vascularized stroma.
• Each duct like structure exhibits a central space, which is
bordered on the periphery by a single layer of tall columnar cells
resembling ameloblasts or pre-ameloblasts.
• The lumen of the duct like structures is generally filled with a
homogenous eosinophilic coagulum.
• Small foci of calcifications are often seen scattered throughout the
lesion .this indicates an abortive attempt towards formation of
enamel, dentin or cementum by the tumor cells.
GDCRI BELLARY 95

96. histopathology
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97. PULP STONES OR PULP CALCIFICATIONS
DEFINTION:
• deposition of calcified masses within the dental pulp for no
apparent reason is called pulp calcification.
• etiology: the etiology of pulp calcification is un known and it
appears to be not related to inflammation, trauma or any
systemic diseases.
PATHOGENSIS:
GDCRI BELLARY 97
Localized metabolic Hyalinization of the tissue
FibrosisMineralization
Formation of
calcified mass
in tissue

98. Types of calcifications
DENTICLES:
• These are small masses of tubular dentin formed within the pulp near
the furcation area of tooth.
PULP STONES:
• Pulp stones are nodular calcified bodies having an organic matrix
and they occur frequently in relation to the coronal pulp.
DIFFUSE LINEAR CALCIFICATIONS OF PULP:
• These are amorphous unorganized, fine fibrilar strands of calcified
masses and are typically formed within the radicular and coronal
pulp.
GDCRI BELLARY 98

99. TYPES OF PULP STONES
TRUE: composed of predominantly of dentin and have dentinal tubules.
they may have a outer layer of pre dentin and are often located
adjacent to the odontoblast cells.
FALSE: composed of concentric layers of calcified material with no
tubular dentinal tubules.
ACCORDING TO LOCATION:
FREE PULP STONES: are surrounded on all sides by pulpal tissue and
not attached to dentinal wall.
ATTACHED PULP STONES: which are attached to dentinal wall of
pulpal chamber.
INTERSTITIAL PULP STONES: are those where the pulp stones have
become surrounded by reactionary or secondary dentin they are
called interstitial pulp stones.
GDCRI BELLARY 99

100. CLINICAL SIGNIFICANCE:
SYMPTOMS:
• Sometimes, it may cause pain from mild pulpal neuralgia to severe
excruciating pain resembling that of tic douloureux as the denticle
can impinge on the nerve of the pulp.
• Difficulty in root canal treatment encountered in extirpating the
pulp.
RADIGRAPHIC FEATURES:
APPEARANCE:
• They are seen as radiopaque structures within the pulp chamber.
SHAPE:
• They may be round or oval.
LOCATION:
• They may occur as single dense mass or several opacities.
GDCRI BELLARY 100

101. radiological presentation
GDCRI BELLARY 101

102. MICROSCOPIC EXAMINATION
TRUE STONE:
• The true pulp stone has an appearance characterized of dentin with
tubules radiating out from the center and predentin around the
periphery.
FALSE STONE:
• The false pulp stone is characterized by concentric layers of
mineralization rather than radiating tubules as seen in true pulp
stones.
GDCRI BELLARY 102

103. HISTOPATHOLOGY
GDCRI BELLARY 103
True pulp stones
False pulp
stone

104. DENTINAL SCLEROSIS
DEFINITION: It is the condition characterized by calcification of the dentinal
tubules of the tooth.
ETIOLOGY:
• Injury to dentin causes
• Aging process
• Abrasion or erosion of teeth.
FEATURES:
• The refractive indices of sclerotic dentin in which the tubules are occluded
are equalized, and such areas become transparent.
• Transparent or sclerotic dentin can be observed in the teeth of elderly
people, especially in the roots.
• Sclerosis reduces the permeability of the dentin and may help prolong pulp
vitality.
• It appears transparent or light in transmitted light and dark in reflected
light.
GDCRI BELLARY 104

105. Microscopic examination
• DEAD TRACTS AND BLIND TRACTS: when dentin is damaged,
odontoblastic processes die or retract leaving empty dentinal tubules.
• Areas with empty dentinal tubules are called dead tracts and appear as
dark areas in ground sections of tooth.
• With time, these dead tracts can become completely filled with mineral
(calcium).
• This region is called blind tracts and appears white in ground sections of
tooth.
• The dentin in blind tract is called sclerotic dentin.
• And the phenomena is called as dentinal sclerosis
GDCRI BELLARY 105

106. MICROSCOPIC EXAMINATION
GDCRI BELLARY 106
DENTIN
SCLEROSIS

107. GDCRI BELLARY 107
THANK YOU

108. REFERENCES
• ORAL RADIOLOGY: PRINCIPLES& INTERPRETATION
STUART C WHITE. MICHAEL.J. PHAROAH
--- 6th EDITION
• BASIC PATHOLOGY AND PRACTICAL BOOK OF PATHOLOGY BY
HARSH MOHAN
---7th EDITION
• MEDICAL PHYSIOLOGY : GUYTON AND HALL
--- 11th EDITION.
• ORAL HISTOLOGY AND EMBRYOLOGY : ORBAN’S
--- 13th EDITION.
• ORAL PATHOLOGY: SHAFER’S
--- 6th EDITION
• OTHER SOURCES: WIKIPEDIA
• HD IMAGES : FROM GOOGLE
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