Soft tissue calcifications and ossifications / oral surgery courses

www.indiandentalacademy.com

Soft tissue calcification & ossification

INDIAN DENTAL ACADEMYLeader in continuing Dental Education


Deposition of calcium salts in tissues other than osteoid or enamel is called pathologic or heterotrophic calcification

Two distinct types of pathologic calcification are recognised:

• Dystrophic calcification • Metastatic calcification

Dystrophic calcification :characterized by deposition of salts in dead or degenerated tissues with normal calcium metabolism and normal serum calcium levels.

Metastatic calcification: Occurs in normal tissues and is associated with dearranged calcium metabolism and hypercalcaemia


Heterotopic ossificationWhen the mineral is deposited in soft

tissue as organised ,well formed bone the process is called heterotopic ossification


Dystrophic calcification• General dystrophic calcification of the oral region• Calcified lymphnodes• Dystrophic calcification in the tonsils• Cysticercosis• Arterial calcification –Arteriosclerosis Calcified atherosclerotic

plaqueIdiopathic calcification:• Sailolith • Phlebolith • Laryngeal cartilage calcification• Rhinolith /anthrolith


Metastatic calcification:• Ossification of the stylohyoid ligament • Osteoma cuts• Myositis ossificans-Localized (traumatic)myosistis

ossificans Progressive myositis

ossificans


General dystrophic calcification of the oral regions

Dystrophic calcification is the precipitation of calcium salts into primary sites of chronic inflamation or dead and dying tissue.

C/F: Common sites: gingiva , tongue , lymphnodes, & cheek • It is usually asymptomatic • A solid mass of calcium salts sometimes can be

palpatedR/F: Fine grains of RO to large, irregular radiopaque particles

(<.5CM)The calcification may be homogeneous or may contain

punctate areasIrregular or indistinct outline


Calcified lymph nodesDystrophic calcification occurs in lymphnodes that have

been chronically inflamed because of various diseases.

Tuberculosis(scrofula or cervical tuberculous adenitis)Sarcoidosis Catscratch disease Rhematoid arthritisSystemic sclerosisLymphomaFungal infectionsMetastases from distant calcifying neoplasams


C/F: • Asymptomatic• Submandibular , superficial and deep cervical

lymphnodes • NODES-bony hard , round or linear masses with

variable mobility


R/F: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

radiopacityEgg shell calcification (RO seen only on the surface of

the node)


Differential diagnosis• Sailolith-has a smooth outline . • Phlebolith- are small & multiple• Histoplasmosis-firm consistency• lymphoma –rubbery consistency

www.indiandentalacademy.comCalcified lymphnodes


Dystrophic calcification in the tonsils

Synonyms: Tonsillar calculi, Tonsillar concretions, & tonsilloliths• Tonsillar calculi are formed when repeated botus of

inflammation enlarge the tonsillar crypts C/F: They present as hard , round , white or yellow objects

projecting from the tonsillar crypts Small calcifications are asymptamaticLarge calcifications produce pain ,swelling, foetis oris,

dysphagiaOlder age groups are commonly


R/F:Location: Mid portion of the mandibular ramusTonsilliths frequently appear on the panoromic

radiograph immedeatly inferior to the mandibular canal

Periphery: ill-definedInternal structure: uniformly radiopaqueD/D: Calcified granulomatous disease-Firn Syphillis-firm Mycosis or lymphoma –firm RO lesions such as dense bony islands


Dystrophic calcification of tonsils


cysticercosis

Human ingests egg or gravid proglattidss

The covering of the egg is digested

The larvae is hatched

It enters blood vessels and lymphatics

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 granuloma formatin scarring and calcification ,these areas in the tissues are called cysticerci


C/F:Mild cases are completely asymptomaticModerate to severe cases have symptoms range

from mild to severe GIT UPSET Epigastric pain Severe nausea and vomiting Seizures,headache Visual disturbancesIrritability


R/F: Location : Muscles of mastication and facial muscles

and suprahyoid muscles and post cervical musculature

Periphery and shape: Multiple well defined elliptical RO resembling grains of

rice Internal structure: Homogeneously RO D/d: Sailolith The small size of the calicified nodules of cysticerci

and their wide spread dissemination ,particularly in brain and muscle are higly suggestive of the diagnosis


Arterial calcificationTwo distict type of arterial

calcification can be identified both radiographically & histologically

• Monckeberg’s medial calcinosis• Calcified atherosclerotic plaque


Monckberg’s medial calcinosis

Synonym: ArteriosclerosisDegeneration and eventual loss of elastic fibers

followed by the deposition of the calcium within the medial coat of vessel.

C/F: • Intially asymptomatic • In later cases cutaneous gangrene peripheral

vascular disease and myositis.• Patients with sturge -weber syndrome also

develop intracranial arterial calcification


R/F: Location : Facial artery . less comonly carotid artery Periphery and shape: It outline an image of the artery ,appears as a

parallel pair of thin RO lines –pipe strem or tram track appereance

In cross section ,involved vessels will display a circular or ring like pattern

D/D: The radiographic appereance of arteriosclerosis is so

distinctve as to be pathognomic of the condition


ARTERIOSCLEROSIS


Calcified atherosclerotic plaque• Dystrophic calcification can occur in the

atherosclerotic plaque over a period of time R/F:LOCATION: It develops at arterial bifurcation , when

calcification has occurred these lesions may be visible in the panoramic radiography in the soft tissues of the neck eighter superior or inferior to the greater cornu of the hyoid bone

PERIPHERY & SHAPE: multiple and irregular in shape and sharply defined from the surrounding tissues

INTERNAL STRUCTURE: heterogeneous radiopacity with radiolucent voids


sialolithSialolith 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 radiographically detectable

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.


C/F: • 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


R/F:LOCATION: Submandibular gland ( 83 to 94 %) 50% lies in the distal portion of

warthons 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 RO Others show evidence of multiple layers of

calcifications


Occlusal view demonstrates a calcifieddeposit in Wharton’s duct.


SAILOLITH IN WHARTONS DUCT


Sialogram of the submandibular gland


Multiple sialoliths and a sialolith of unusual size in thesubmandibular duct :A case report


InvestigationsSubmandibular 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 R placed in the buccal vestibule & the central x-ray

directed through cheekAP. skull view Lateral skull projection.If non calcified stones are suspected SAILOGRAPHY is helpful CT scan MRIRadionucleide salivary imaging


D/D: 1) A calcified lymph node-Incidence2) An avulsed or embedded tooth3) A phlebolith –Symptoms of sailadenitis are

absent4) 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


phlebolithsPhleboliths are calcified thrombi found in veins, or the

sinusoidal vessels of hemangiomas C/F:In head and neck , phlebolith nearly always signals the

presence of a hemangiomaOr 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


R/F: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 appeareance of laminations giving a bull’s eye or target appeareance ;a RL centre may be seen .

D/D: SailolithTonsillolithsArterial calcifications.Myositis ossificans CysticercosisCalcified acne – The are superficial lesions


Phlebolith


A case report of intramuscular hemangioma presenting with multiple phleboliths



Laryngeal cartilage calcifications

A small paired triticeous cartilageous are found within the lateral thyrohyoid ligaments

Both the thyroid and triticeous catilages contains hyaline cartilage which has a tendency to calcify with advancing age


R/F: Location: located on lateral view within the

pharygeal 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 ROD/D: Calcified atheromatous plaque in the carotid

bifurcation


Laryngeal cartilage calcifications


Rhinolith or anthrolith

Calcareous concretions that occur in the nose(rhinolith) or the antrum of the maxillary sinus(anthroliths) arise from the deposition of nasal,lacrimal and inflamatory mineral salts

Anthrolith Rhinolith

Endogenous Exogenous substance

Adult population Pediatric population


C/F:Unilateral purulent

rhinorrhea,Sinusitis ,Headache,Epistaxis,Anosomia feverR/F:The stones have variety of shapes and sizes & the internal

structure may present as homogeneous or hetergeneous ROD/D:OsteomaComplex OdontomaMatured cementomaPeriapical condensing osteitis Palatine torus Impacted teethAla of the nose

RL borders


Periapical radiographs demonstrating anthrolith

Occlusal radiograph deomstrating anthrolith


OSSIFICATION OF THE STYLOHYOID LIGAMENT

Ossification of the stylohyoid ligament usually extends downward from the base of the skull and commonly occurs bilaterally

C/F:Symptoms related to this ossified ligament are

termed eagle sndrome Classic eagle syndrome: cranial nerve impingementCarotid artery syndrome Intense pain in pharynx during swallowing & turnign

head or opening the mouth especially on yawning


OSSIFICATION OF THE STYLOHYOID LIGAMENT


R/F:Location: The linear ossification extends forward

from the region of the mastoid process and crosses the posteroinferio aspect of the ramus towards the hyoid bone

Shape: Appears as a long tapering thin RO process .It normally varies from 0.5 to 2.5 cm in length.Internal structure: homogeneuously RO D/D:Tmj dysfunctionMANAGEMENT : NO TREATMENT IS REQUIRED


OSTEOMA CUTISRare soft tissue ossification in the skin 85% of the cases occur secondary to acne of long

duration developing ina scar or chronic inflamatory dermatosis

C/F: 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 )


R/G:Location: cheek & lip regionsPeriphery & shape: smoothly outlined RO washer

shaped images ,single or mutliple RO usually measuring 0.1 to 5cm

Internal structure: homogeneously RO but usally has a Rl centre ( donut appereance )

D/d: Myositis ossificans Calcinosis cutis


Osteoma cutis


MYOSITIS OSSIFICANS

In myositis ossificans;fibrous tissue & heterotopic bone form within the interstitial tissue of muscle and associated tendons and ligaments

Secondary destruction and atrophy of the muscle occur

2 forms: localized and progressive


Localized (trumatic)myositis ossificans

Synonym: postraumatic myositis ossificans solitary myositisEtiology: acute or chronic trauma.heavy muscular

strain muscle injury from multiple injectionsC/F: YOUNG MEN • The site of the precipitated trauma remains

swollen ,tender and painful • The overylying skin may be red and inflamed • Opening of jaw may be difficult


Radiographic features• Location: masseter and sternocledomastoid the ant 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 RO 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 6moths- it becomes denser and more defined


D/D:Ossification of stylohyoid ligament Soft tissue calcifications


Trumatic myositis ossificans


Progressive myositis ossificans

Rare heriditary disease with autosomal dominant transmission

Affects children before 6yrs of age Occasionally seen in infants MalesProgressve formation of heterotrophic bone

occurs within the interstetial 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

D/D:Rheumatiod arthritiscalcinosis


Myositis ossificans

Myositis ossificans seen as bilateral linear calcifications of the sternohyoid muscels


Excessive ossification temporalis and masseter


References :• Principles & interpretation of oral radiology

6th edition;stuartc.white,michael j.pharoah• Normank.wood.paul w.goaz-differential

diagnosis of oral and maxillofacial lesions-5th edition