Part Three: Appendices










Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar.
© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/hubar/radiology
200
Appendix 2
X‐radiation Concerns ofPatients:
QuestionandAnswer Format
Patients may read an article in a magazine or on
the internet, hear a report in the news or listen
to other so‐called authorities with information
that contradicts the x‐ray imaging protocol
practiced by their personal dentists. A patient
may then confront their dental professional
about these concerns. The typical patient wants
a concise answer that is easy to understand.
In cases where the need or frequency of x‐ray
exposure is questioned, dental auxiliaries are
often the dental professional of choice for the
answers. This author believes that the public’s
perception of dental auxiliaries is that they are
very knowledgeable about dentistry, they do
not have x‐ray quotas to fill and they do not
receive a bonus for exposing additional numbers
of x‐ray images. Therefore, a dental auxiliary is
perceived as someone who can offer unbiased
answers to their questions. Here are ten ques-
tions that a patient may ask their dental profes-
sional prior to being exposed to x-radiation.
Each question is accompanied by a simple
response that should educate and allay the
fears of the patient.
1. How often should Iget x rays taken?
Response: The frequency and type of dental
x‐ray images required will vary from one
patient to another. This is because our mouths
are all different. Someone who has never had a
dental cavity in their entire life may only need
a couple of bitewing x rays taken every few
years to confirm that no problems have devel-
oped. While someone else who is very prone
to tooth decay may need multiple x rays taken,
for example every 6 months. Our office only
takes the minimal number of x rays to ensure
that you receive the best oral care.
2. How much radiation amIreceiving
fromdental x rays?
Response: You may not realize it, but you are
continually receiving a low dose of radiation
from everything around you. Radiation comes
from the sun, the ground you walk on, the
buildings that surround you, etc. We call this

Appendix 2 201
natural background radiation. Our typical
dental exam x rays amount to less than 1 day’s
worth of normal radiation and that is regard-
less of whether you are spending time indoors
or outdoors in the sun all day. Do you ever
travel in a plane? Flying in a plane at a higher
altitude exposes you typically to more radiation
than our dental x rays do. We also take all
precautions to protect you from unnecessary
radiation by using the latest technology.
3. Can Iget cancer fromdental x rays?
Response: Going back to the discovery of xrays
in the late 1800s, there has not been one proven
instance of a patient getting cancer from dental
x rays. And today, with our improved technol-
ogy, you receive far less radiation than dental
patients did back in those early days.
4. Why do Ineed towear
aprotective apron fordental x rays
andwhy does theassistant leave
theroom before taking my x rays,
ifdental x rays are sosafe?
Response: Our office prides itself on using
whatever means we can to help reduce any
unnecessary exposure both to you and to me.
Our policy is: if it is simple to do, then we
should do it. To protect you from x rays that
may bounce off your teeth and jaws in different
directions, I will place a protective apron on
you, and to protect me from those same x rays,
I will stand outside the room.
5. Your protective apron does not have
athyroid collar, why not?
Response: Depending on the type of x rays we
require, the collar can actually get in the way
of the x‐ray beam and block the x rays making
it impossible to see your teeth and jaws on the
image. If that happened, then we would have
to expose you again, with the collar removed.
So to avoid having to re‐expose you, we leave
it off when necessary. You may not realize it,
but some of x rays that bounce off your teeth
and bones exit your jaws through your neck.
While you are wearing a thyroid collar, these
x rays can actually bounce backward off the
collar and expose your thyroid gland to addi-
tional x rays that would have just exited your
body.
6. I ampregnant, should Iget dental
xrays taken?
Response: To be 100% safe, it is always best to
avoid having any x‐ray images taken at any
stage of your pregnancy. Treating your dental
problem is essential to the good health of your
developing baby. If you have an untreated
dental infection, more harm could result to the
baby than by taking a few x rays and properly
treating the problematic tooth. We will take
the minimum number of x rays to treat that
problem and we will take all precautions to
reduce the radiation exposure to you and your
baby. That means, to protect your baby, I will
place a protective apron on you which will
absorb over 99% of the few stray x rays that
might bounce off your teeth and jaws. You and
your baby will be fully protected.
7. When should my child first get
dental x rays taken?
Response: It is vital to follow the development
of the baby teeth and the developing adult teeth.
Every child will react differently to having dental
instruments placed in their mouths. Pediatric
dentists recommend first seeing children at a
few years of age. At that time, a minimal number
of dental x rays may be attempted to properly
examine a child’s teeth.

202 Appendix 2
8. Will Iglow inthedark after all
ofthex rays that Ireceived at
thedental office?
Response: Never! Dental x rays do not make
people glow regardless of the exposure dose.
The “glowing” that you are referring to is
related to radioactive materials found in nature.
X rays are not radioactive.
9. What are 3‐D x rays?
Response: In many dental offices today, there
is a new type of sophisticated dental x‐ray
unit. It is called a cone beam computed tomography
(CBCT) x‐ray unit. It produces three‐dimensional
views of your jaws. It does not replace our
standard x rays because the images do not
show fine details well, like small cavities, and
it requires more radiation exposure compared
with standard x‐ray images. However, it
is invaluable for patients requiring dental
implants. It is also used sometimes for cos-
metic surgery, orthodontics, root canals and
diagnosing pathology.
10. Why does thedentist require
additional 3‐D x rays before placing
my dental implant?
Response: Standard dental x rays, like panoramic
x rays, only show the outer surface of the bones
and teeth in two dimensions and these x‐ray
images are somewhat distorted. It is not a tech-
nique error but rather it is a physical problem
built into that type of x‐ray equipment, which
results in unavoidably distorted x rays of the teeth
and bones. For successful implant placement, it is
critical to have accurate images in all three dimen-
sions showing the precise size and shape of the
bone where the implant will be placed. CBCT
provides us with this vital missing information.
Cone beam images also accurately show the
position of the nerve in the jaw so we can avoid
damaging it when placing your dental implant.

Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar.
© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/hubar/radiology
203
Appendix 3
Helpful Tips forDifficult Patients
1. Hypersensitive gag reflex
A gag reflex is also termed a pharyngeal reflex or
a laryngeal spasm. It is a reflexive contraction of
the posterior region of the throat that includes
the back of the tongue, the roof of the mouth
and the tonsillar area. The gag reflex is typically
triggered by tactile stimulation (i.e. physical
contact). However, a patient’s hypersensitive
gag reflex may be triggered by the mere sight of
an intraoral x‐ray instrument. A hypersensitive
gag reflex is of particular concern when per-
forming intraoral imaging procedures. (Note:
Some people do not have any gag reflex,
possibly due to a medical condition such as
vagus or glossopharyngeal nerve damage.)
The maxillary molar view is often the most
problematic area for patients. If multiple
regions of the mouth are to be imaged, the
author recommends that the operator complete
all of the other areas first and then return to
image the maxillary molar region at the very
end. If a patient is predisposed to gagging,
starting in the maxillary molar region may
stress the patient so much that it may be impos-
sible to continue. A consequence of this might
be the inability for the operator to image the
anterior region of the mouth, an area that often
does not trigger a gag reflex. If a full mouth
series of images is required, then the operator
should wait until nearing the end of the proce-
dure to casually inform the patient that only a
couple of maxillary molars remain. Knowing
that only one or two images remain to be taken
may allow the patient to persevere and briefly
permit the operator to complete the series.
Most importantly, when faced with a patient
having a hypersensitive gag reflex, the operator
should perform the intraoral procedures as expe-
ditiously as possible. That means pre‐setting the
exposure time, kilovoltage and milliamperage
and pre‐positioning the PID prior to inserting
the receptor into the patient’s mouth. In addi-
tion, only the operator should be in the room
with the patient during the procedure. If other
office personnel or family members are present
to assist, they should be outside the operatory to
avoid unnecessary delays clearing the room to
permit immediate exposure once the receptor is
inserted into the patient’s mouth. Time is of the
essence!
Utilizing the distal oblique technique might
be advantageous in some cases (see Section K).
Even though the distal oblique angulation will

204 Appendix 3
likely overlap images of the crowns, the peria-
pical areas usually will be clearly visible. The
crowns can then be visualized on bitewing
images. In general, if bitewing images are
prescribed in addition to periapical images, it
is recommended that the bitewings always be
imaged at the outset. Bitewing images are
well tolerated by most patients and they offer
additional information that is not evident in
other views.
Distractions are useful ploys to counteract
gagging. Instructing the patient to breathe
deeply through their nose may calm and sub-
due the gag reflex. Additionally, instructing the
patient to raise one arm and one leg prior to
inserting the receptor has also been shown to
help. The patient’s need to concentrate on keep-
ing an arm and a leg raised may offer enough
distraction for the individual to forget about the
instrumentation being placed intraorally.
More tangible remedies include swabbing
both the hard and soft palate with a topical
analgesic. This will temporarily anaesthetize
the sensitive regions and generally allow
placement of the intraoral instrument properly.
Similarly, gargling with a mouth rinse or sprin-
kling salt on the patient’s tongue immediately
prior to instrument placement may also reduce
a patient’s gag reflex. If there is a trained indi-
vidual in the dental office that can perform
hypnosis on the patient and the patient is
compliant, this may remedy a hypersensitive
gag reflex to permit placement of the intraoral
instrumentation.
If none of the remedies discussed above work,
the operator should supplement any intraoral
images acquired with extraoral imaging, such
as a panoramic projection. Some newer pano-
ramic units also claim to offer software to cap-
ture bitewing images. However the bitewing
images attained with a panoramic unit will
not be as diagnostic as conventional intraoral
bitewing images simply due to using different
geometric principles.
It is important to note that if a patient is
intolerant at any time during the procedure, the
operator should suggest terminating the proce-
dure that day and attempting again on another
day. The risk to the dental practice is that a
traumatized patient may decide not to return to
the office for future treatment.
2. Small mouth/shallow palate/
constricted arch/torus
Solid‐state digital receptors do not adapt well
to situations where space is limited. The prob-
lem here is that current receptors are rigid and
are relatively bulky in size. Patients with a
narrow arch, shallow palate or mandible or
the presence of a torus complicate proper
placement of the receptor for performing the
paralleling technique. Options for the operator
are limited. Using a PSP plate is preferable in
these scenarios. PSP plates are thinner and are
flexible, much like dental x‐ray film. Rarely will
a dental practice have both solid‐state and PSP
receptors because of the high financial cost. PSP
systems are currently unpopular with a major-
ity of dentists because of the added time and
steps required for scanning the individual PSP
plates. If the operator uses a solid‐state recep-
tor, substituting a size 2 receptor with a smaller
receptor size 1 or 0 should help. However,
the operator should be aware that the smaller
receptor is also shorter and that it may not be
long enough to capture the length of the entire
tooth on a single image. The operator should
focus on the region of primary interest but take
whatever images are necessary to perform a
proper diagnosis.
A shallow palate necessitates using the
bisecting angle technique. If the operator
attempts performing the paralleling technique,
it will likely result in a foreshortened image
caused by excessive vertical angulation of the
x‐ray beam. The presence of a palatal torus in a
deep palatal vault basically has the same effect
as a shallow palate alone. Similarly, a shallow
floor of the mouth (i.e. inadequate vertical
height of the mandibular ridge) may prevent the

Appendix 3 205
operator from fully seating the receptor verti-
cally to image the periapical region. A shallow
palate and a shallow floor of the mouth are
particularly common in children, simply because
of incomplete growth and development. The
fact is that it may be impossible to acquire
diagnostic intraoral images on some patients
and the practitioner must then rely strictly on
extraoral images. As mentioned earlier, some
panoramic units offer software to capture bite-
wing images but they will not be as diagnostic
as conventional intraoral bitewing images.
3. Large frenulum
The lingual frenulum is a small fold of mucous
membrane in the midline that extends from the
floor of the mouth to the ventral surface of the
tongue. A large lingual frenulum may restrict
the ability of the patient to raise his or her
tongue for the operator to properly position the
intraoral receptor beneath it for the mandibular
anterior periapical views. To counteract this
problem, the operator may simply place the
instrument on the dorsal surface of the tongue
and have the patient fully close the jaws together.
Generally, this will adequately capture the
anterior periapical regions. Another option is
for the operator to use the bisecting angle tech-
nique. In this case, the receptor should be
positioned as far lingually as possible and the
angulation of the x‐ray beam can then be deter-
mined using the bisecting angle formula.
Positioning the receptor in the posterior regions
should not be affected by the lingual frenulum
(synonym: frenum).
4. Trismus
Trismus is a spasm of the muscles of mastica-
tion that prevent the patient from opening his
or her mouth appreciably. Insufficient opening
of the mandible and maxilla may prevent inser-
tion of the receptor instrumentation into the
patient’s mouth. Extraoral imaging may be the
only method for imaging the teeth if the bulki-
ness of a solid‐state receptor combined with the
x‐ray instrument is too large to insert. Without
the convenience of extraoral imaging, the
operator can remove the x‐ray instrument and
position the receptor itself horizontally onto the
occlusal surfaces of the teeth and perform
multiple occlusal technique views to acquire
some intraoral images. If a PSP plate is availa-
ble, the operator may substitute a hemostat
for the standard instrument. A hemostat, being
less bulky, would permit sliding the receptor
horizontally between the teeth and, once inside
the mouth, the receptor could be flipped
upright and positioned apically. Depending on
the final vertical orientation of the receptor, the
bisecting angle or paralleling technique can
then be used by the operator.
5. Cuspid superimposition
The position of the cuspid is normally situated
along the anterior curvatures of both the max-
illa and the mandible. The curve of either arch
forces positioning the receptor obliquely behind
the cuspid. The resultant horizontal angulation
invariably projects the lingual cusp of the first
premolar over the distal surface of the cuspid.
Consequently, superimposition of the cuspid
and first premolar contacts in the cuspid view
is commonplace. However, the overlapped
contacts between the cuspid and first premolar
should ideally be open in the premolar periapi-
cal and bitewing images. One caveat here is
that a solid‐state receptor may be too bulky to
be positioned far enough anteriorly to capture
the distal of the cuspid. The operator can com-
promise by angling the receptor horizontally
across the midline. This should position the
receptor far enough anteriorly to capture and
open the distal contact of the cuspid. However
in this orientation, the horizontal angulation of
the PID will likely produce some uneven magni-
fication and overlapping of the two premolars.

206 Appendix 3
Consequently, additional traditional premolar
views would need to be imaged to complete
the series.
6. Rubber dam
Dental procedures, such as endodontic or restor-
ative treatments, typically involve the use of a
rubber dam which will complicate intraoral
receptor positioning. Regardless if the rubber
dam frame is metal or plastic, it should be
removed to facilitate placement of the receptor.
Customized x‐ray instruments are commercially
available (e.g. Endo‐Ray®) to accommodate the
rubber dam, the rubber dam clamp and possible
endodontic instruments. Other options may
include using tongue depressors (see Figs Y12
and Y13) and hemostats. Hemostats should only
be used with PSP plates and not solid‐state recep-
tors. All solid‐state receptors are much thicker
than PSP plates and may be damaged by tightly
clamping the hemostat onto them. Generally, the
bisecting angle technique must be used because
the receptor cannot be positioned or maintained
parallel to the tooth of interest. When necessary,
patients may be requested to hold the x‐ray
instrument with their own hand because it may
be physically impossible to occlude the teeth
together to support the instrument.
7. Third molar imaging
Intraoral imaging of a third molar is often
challenging for even an experienced operator.
In addition, it is not uncommon for an unerupted
third molar to be horizontally impacted. This
will further compound the difficulty level in
attempting to acquire an image of the entire
tooth. Gagging often becomes an issue when
placing receptors far enough posteriorly to
image third molars, particularly maxillary third
molars. Tips for treating gagging patients are
discussed earlier in this appendix and may be
used with some success in this situation.
Alternatively, the distal oblique intraoral tech-
nique, also previously discussed, would be
worth attempting. In this scenario, the recep-
tor would only need to be positioned in the
premolar region and then angled across the
midline to capture the image. Ultimately it may
be impossible to acquire an intraoral image of
a third molar and an extraoral image such as a
two‐dimensional panoramic projection is the
alternative. Besides the procedure being more
comfortable for the patient, a panoramic projec-
tion will image all of the third molars simultane-
ously. A CBCT may alternatively be prescribed
for obtaining the three‐dimensional relation-
ship of the third molars to their surrounding
structures.

Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar.
© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/hubar/radiology
207
Appendix 4
Deficiencies ofX‐ray Imaging Terminology
Soap bubble, honeycomb and multilocular are terms
frequently used interchangeably to describe simi-
lar radiologic features. Do these terms describe a
single entity or are they characteristic of different
osseous pathoses? The nomenclature used in den-
tal radiology is confusing: the dental literature
shows linguistic ambiguity and impreciseness.
Descriptive terms selected to describe lesions of the
jaws are often ill‐defined or may possibly be unde-
fined. Although honeycomb and soap bubble are fre-
quently used interchangeably to describe the same
ameloblastoma, the Concise English dictionary
provides different definitions for the two descrip-
tors. Honeycomb is defined as a “regular arrange-
ment of numerous, small, uniform compartments,”
whereas soap bubble is described as “numerous,
non‐uniform compartments of varying size and
arranged in an irregular pattern.” Additional
examples of ambiguous terminology presently in
use include lace‐like, moth‐eaten, worm‐eaten, sun ray,
sunburst, ground glass and cotton wool.
To investigate this perceived problem in
communication with current radiographic
terminology, the author conducted a limited
survey. The terms included in the study were
cotton wool, ground glass, honeycomb, multilocular
and soap bubble. Definitions for these terms
were obtained from five oral and maxillofacial
radiologists, an oral and maxillofacial surgeon,
an attorney, two linguists and an English
language professor.
Survey results
The following definitions were supplied by
the ten respondents.
Cotton wool appearance (see Fig. X6)
Oral and maxillofacial radiologists:
1. Irregular, ill‐defined radiopaque patches
2. Fluffy, rounded, opaque mass without dis-
tinct margins
3. Rounded radiopacities within an area of
more radiolucent bone
4. Numerous foci of radiopacity intermingled
with areas of radiolucency
5. Radiopaque globular or spherical structures
with reduced numbers and thicknesses of
trabeculae and haphazard or linear pattern
of those that remain

208 Appendix 4
Oral and maxillofacial surgeon: Like balls of
cotton, fuzzy edges, centrally radiopaque
Attorney: Large, round, soft, puffy area, perhaps
with soft wisps or tendrils; white or light in
color relative to the background
Linguists:
1. Composed of a mass of fluffy white threads
2. Frothy white with no real shape except a
general roundness; edges ill‐defined
English professor: Spherical fibrous mass(es)
Ground glass appearance (see Fig. X3)
Oral and maxillofacial radiologists:
1. Fine, almost structureless granular texture;
may be more or less radiopaque than normal
2. Granular radiographic appearance resem-
bling an orange peel or pebbled texture;
variable margin patterns
3. Homogeneous appearance of bone resulting
from loss of contrast between trabeculae
and marrow spaces
4. Appearance of glass with light‐diffusing
surface produced by etching or abrasion
(i.e. hazy, filmy appearance); many trabeculae
of bone of approximately equal size are
radiographically apparent
5. Resembling glass which has been pulver-
ized into fine granules
Oral and maxillofacial surgeon: Amorphous
radiopaque appearance
Attorney: Evenly sized small compact grains
Linguists:
1. Composed of tiny, hard, shiny particles
2. Fairly flat and composed of small hard bits
resembling granulated sugar
English professor: Crystalline‐appearance of
chunks with hard edges
Honeycomb appearance (see Fig. X5)
Oral and maxillofacial radiologists:
1. Multilocular lesion with compartments
smaller than those of “soap bubble”
appearance
2. Contiguous polygonal radiolucent regions,
which may vary in border definition
3. Numerous small compartments with septal
arrangement resembling a honeycomb
4. Similar to “multilocular” but with more
linear septae
5. Not used and no opinion
Oral and maxillofacial surgeon: Not used
Attorney: Well‐defined, roughly similar, round
or squarish geometric areas branching out over
relatively wide areas; separate shapes appear
empty
Linguists:
1. Composed of regularly joined polygons
2. Framework of adjoining octagonally‐shaped
hollow cells
English professor: Hexagonal structures
Multilocular appearance (see Fig. X1)
Oral and maxillofacial radiologists:
1. Radiolucency produced by many coalescing
and overlapping compartments in bone;
often representative of a neoplastic or cystic
process
2. Radiolucency with more than one locule,
having many compartments
3. Usually pathologic well‐corticated radiolu-
cencies; internal septae, total or partially
separate compartments (in two‐dimensions)
within the boundaries of the lesion
4. Radiolucent lesion with two or more round
or ovoid compartments which appear to be

Appendix 4 209
partially separated from one another by
incomplete septae
5. Having many compartments
Oral and maxillofacial surgeon: Multicystic or
soap bubble appearance
Attorney: Many circles in a well‐defined area
Linguists:
1. Unknown
2. Unknown
English professor: Spheres or ovals within a
larger body
Soap bubble appearance (see Fig. X1)
Oral and maxillofacial radiologists:
1. Multilocular lesion consisting of several
circular compartments which vary in size
and usually appear to be somewhat
overlapped
2. Multilocular radiolucency with many loc-
ules varying in size from large to very small
3. Radiolucent compartments of variable size,
faint septae and poorly defined borders
4. Similar to “multilocular” but with more
rounded septae
5. Similar to “multilocular” but with many
loculations; reminiscent of soap bubbles;
bony septae between locules are very fine
whereas in “multilocular” lesions the septae
can be coarse
Oral and maxillofacial surgeon: Multilocular
with compartments of varying size
Attorney: Many small spheres clustered together;
light density, puffy and soft, and empty or clear
in appearance
Linguists:
1. Composed of mass of iridescent spheres of
numerous sizes
2. Large shiny balls, each ball or sphere
impinging on and partially adhering to
other balls or spheres
English professor: Cluster of spherical masses
with flat adjoining surfaces (i.e. with mutual
walls)
Examination of the definitions just listed shows
the discrepancies in the respondents’ percep-
tions. Hence it is apparent that terms currently
used by dental professionals to describe x‐ray
images are ambiguous. Interpretation is based
on individuals’ own conceptions and past edu-
cation. Such impreciseness could lead to a gap
in communication of significance to patient
treatment and outcome.
Gill et al. (1973) evaluated observer variations
in history taking and physical examination. He
found disagreement was significantly reduced
when a common set of definitions was devel-
oped and used by the participating physicians. It
is suggested that a standardized set of definitions
of radiographic features, if formulated, could
reduce the margin of error currently resulting
from subjective interpretation and definitional
variability among dental diagnosticians.

Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar.
© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/hubar/radiology
210
Appendix 5
Tools forDifferential Diagnosis
There are seven criteria useful for describing
osseous lesions to formulate a differential
diagnosis:
1. Number
2. Location
3. Density
4. Shape
5. Size
6. Borders
7. Changes to surrounding anatomic struc-
tures such as root resorption and tooth
displacement
Note: Each criterion listed above has limited
value on its own, but a combination of all
seven can significantly improve the differen-
tial diagnosis. Ultimately a biopsy of the
lesion may still be required to confirm the
diagnosis.
1. Number
How many anomalies are present? Excluding
tooth‐specific pathology (e.g. caries) and gen-
eralized pathology (e.g. metabolic disease) that
may encompass one or both dental arches
entirely, the vast majority of osseous lesions
appear single in number. Consequently, when a
couple or more lesions are observed, it can
assist the clinician in narrowing down the
differential diagnosis. For example, bilateral
radiolucencies in the rami of young individuals
are very characteristic for cherubism.
2. Location
Where is the anomaly located? Is it in a tooth‐
bearing region or a non‐tooth‐bearing region?
This information can help to differentiate
odontogenic versus non‐odontogenic pathol-
ogy from the diagnosis. Many types of osseous
pathology characteristically occur in one region
of the mandible or maxilla. However, with the
paucity of cases reported in the dental litera-
ture for some types of pathology, one must not
eliminate an entity because it is located in a
non‐characteristic region of the facial complex.
Location often helps to rank diagnoses higher
or lower in the differential depending on
whether it is found within or outside of its
typical region.

Appendix 5 211
3. Density
Is the anomaly radiolucent, radiopaque or
mixed (i.e. combination of radiolucent and
radiopaque)? Density is invaluable for dis-
cerning the composition of the anomaly.
Radiolucent areas typically indicate a destruc-
tive process within the area in question.
Excluding an air space, radiolucent areas
will be composed of soft tissue, fluids or a
combination of the two. A radiopaque area
typically indicates a calcifying (i.e. ossifying)
process. A mixed radiolucent and radiopaque
region may be either a destructive process or a
calcifying process. For example, osteomyelitis
is an infection leading to destruction of bone.
While an ossifying fibroma is a calcifying pro-
cess that may show both radiopaque and radi-
olucent regions during its intermediate stage
of development. Interestingly, one must be
cognizant about soft tissue and fluids located
within more radiolucent areas of the orofacial
complex (e.g. sinus). Contrary to what one
would expect, in this situation soft tissue and
fluids will not appear radiolucent but rather
will have a somewhat radiopaque appearance.
The reason is that soft tissue and fluids will
attenuate additional radiation, giving it a
radiopaque appearance relative to a less dense
surrounding region. If the same soft tissue or
fluid was located within a more opaque region
like the ramus, it would typically appear radi-
olucent. Density is the most important finding
for deriving a differential diagnosis.
4. Shape
Is the area in question, for example, round,
elliptical, square or amorphous? Quite often,
shape is used to characteristically describe
the typical appearance of a particular disease
process. Soap bubble
appearance is often asso-
ciated with an ameloblastoma; honeycomb
appearance is often associated with a myxoma;
sunburst
appearance is associated with an
osteosarcoma, etc. The problem is that these
radiologic terms are rarely defined in publica-
tions, leaving the interpretation up to the
observer. More importantly, these appearances
often only appear in the late stages of disease
development. As a result, observing an earlier
stage of disease development, the lesion may
appear very different and the clinician may
incorrectly discard that disease entity from the
differential diagnosis because it did not have
the classic radiologic appearance.
Shape indirectly can assist the clinician in
assessing the consistency of the lesion. A round
radiolucency would be more indicative of a fluid
core. The dynamics of a round‐shaped radiolu-
cency is similar to a balloon. As the balloon
inflates and as the radiolucency enlarges, they
expand evenly in all directions. Of course shape
exceptions will occur when an enlarging radio-
lucent area encounters an obstacle, e.g. a root of
a tooth. The obstacle can act as a barrier and
force the expanding lesion to detour around it,
thus altering the symmetric shape. Conversely,
an irregular‐shaped radiolucency not modified
by other structures might be more indicative of a
soft tissue composition. Similar to flowers bud-
ding on a stem of a plant, a soft tissue lesion may
bud out in different directions.
5. Size
How large is the area of concern? Size can be a
general indicator of the period of time the lesion
has been developing. One would generally
expect that a larger lesion would have required
a longer period of time to grow. A large lesion
could also imply that it is benign in nature,
particularly if it is painless. If the lesion was
painful, it is more likely that the patient would
have sought treatment earlier when the lesion
was smaller in size. A great deal of weight
should not be applied to this interpretation
(i.e. benign versus malignant), but combined
with all the other findings, it may help to modify
the differential diagnosis.

212 Appendix 5
For the differential diagnosis, size does not
have to be 100% accurate. However, descriptive
terms such as large, big and small are all too
subjective and as a result should not be used by
clinicians. Each person may interpret these terms
very differently. If you are consulting with another
clinician over the telephone about a case, it is
best to describe the size of the area using either
an approximate numeric measurement or simply
comparing its size to a commonly known object
(e.g. size of a dime) that others will be familiar
with. This will better assist the other clinician
to mentally envision the lesion.
6. Borders
Is the area well-demarcated, does it have a
corticated border, is it difficult to differentiate
abnormal from normal tissue? Well‐defined
borders are typically indicative of a slower
growing, non‐malignant lesion versus an ill‐
defined lesion. An ill‐defined lesion would
be more indicative of an aggressive, possibly
malignant lesion. Well‐corticated borders are
indicative of the body’s attempt at curtailing
the lesion’s growth; in essence the body’s
defense is attempting to wall it off. Aggressive,
rapidly growing lesions will not be easily con-
tained, will spread around obstacles (e.g. teeth)
and will often appear with ill‐defined borders.
Be certain not to confuse ill‐defined borders
with poor diagnostic quality x‐ray images.
7. Changes tosurrounding anatomic
structures
Radiographic changes such as expansion of
the cortical plate, root resorption and tooth
displacement are useful for determining the
behavior of the lesion. Expansion of the cortical
plate versus destruction of it is indicative of a
slower‐growing, less aggressive lesion. Root
resorption is indicative of a slower‐growing
or long‐standing lesion because of the time
it would take to cause destruction of a
solid tooth structure. Pathologic tooth dis-
placement, like orthodontic tooth movement,
is not a quick process. It would indicate
a slower‐growing lesion. A rapidly growing
lesion would quickly spread around the
tooth. Consequently, changes to normal
anatomic structures are worth noting to help
ascertain the behavior of the lesion in
question.
In conclusion, combining all of the informa-
tion from the seven criteria discussed above
will give the clinician a significant amount of
information to help construct a concise differ-
ential diagnosis. This is especially critical in
aprivate practice scenario when the clini cian
has a patient who presents with some
unknown oral pathology. The practice may
not have advanced imaging modalities like
CBCT or have a pathologist’s biopsy report at
the initial visit. Yet the patient expects some
information about the seriousness of the
situation before departing the dental office.
Fortunately, the clinician can dissect signifi-
cant amounts of information from conven-
tional x‐ray images and combine that with
information derived from the medical history
and dental exam to give the patient an intelli-
gent answer as to the behavior of the lesion
and how to proceed. It may or may not be
enough information to accurately diagnose
the lesion but at least the behavior of the
pathosis should be evident.

Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar.
© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/hubar/radiology
213
Appendix 6
Table ofRadiation Units
Traditional units SI units Conversion
Roentgen (R) Coulombs per kilogram (C/kg) 2.58 × 10
–4
C/kg = 1 R
Radiation absorbed dose (rad) Gray (Gy) 1 Gy = 100 rad
Roentgen equivalent man (rem) Sievert (Sv) 1 Sv = 100 rem

Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar.
© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/hubar/radiology
214
Appendix 7
Table ofAnatomic Landmarks
Tooth
Dentin
Cementum
Enamel
Pulp
Tooth‐related structures
Alveolar bone (cancellous and cortical bone)
Alveolar crest
Lamina dura
Periodontal ligament space
Landmarks associated withthemaxilla
Radiopaque
Anterior nasal spine
Hamular process
Nasal concha
Nasolabial fold
Nose (soft tissue)
Pterygoid plates
Torus (aka palatine torus, torus
palatinus;pl.tori)
Zygoma and zygomatic process
Radiolucent
Incisive foramen
Lateral fossa
Lip line
Maxillary sinus
Mid‐palatine suture
(aka intermaxillary suture)
Nasal fossa
Nasolacrimal canal
Landmarks associated with the
mandible
Radiopaque
Coronoid process
Genial tubercles

Appendix 7 215
Inferior border of the mandible
Lip line (soft tissue)
Mental ridge (aka mental process)
Oblique ridge, external
Oblique ridge, internal
Torus (aka mandibular torus, torus
mandibularis; pl. tori)
Radiolucent
Lingual foramen
Mandibular canal
Mental foramen
Mental fossa
Nutrient canals
Submandibular gland fossa

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Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology200Appendix 2X‐radiation Concerns ofPatients: QuestionandAnswer FormatPatients may read an article in a magazine or on the internet, hear a report in the news or listen to other so‐called authorities with information that contradicts the x‐ray imaging protocol practiced by their personal dentists. A patient may then confront their dental professional about these concerns. The typical patient wants a concise answer that is easy to understand. In cases where the need or frequency of x‐ray exposure is questioned, dental auxiliaries are often the dental professional of choice for the answers. This author believes that the public’s perception of dental auxiliaries is that they are very knowledgeable about dentistry, they do not have x‐ray quotas to fill and they do not receive a bonus for exposing additional numbers of x‐ray images. Therefore, a dental auxiliary is perceived as someone who can offer unbiased answers to their questions. Here are ten ques-tions that a patient may ask their dental profes-sional prior to being exposed to x-radiation. Each question is accompanied by a simple response that should educate and allay the fears of the patient.1. How often should Iget x rays taken?Response: The frequency and type of dental x‐ray images required will vary from one patient to another. This is because our mouths are all different. Someone who has never had a dental cavity in their entire life may only need a couple of bitewing x rays taken every few years to confirm that no problems have devel-oped. While someone else who is very prone to tooth decay may need multiple x rays taken, for example every 6 months. Our office only takes the minimal number of x rays to ensure that you receive the best oral care.2. How much radiation amIreceiving fromdental x rays?Response: You may not realize it, but you are continually receiving a low dose of radiation from everything around you. Radiation comes from the sun, the ground you walk on, the buildings that surround you, etc. We call this Appendix 2 201natural background radiation. Our typical dental exam x rays amount to less than 1 day’s worth of normal radiation and that is regard-less of whether you are spending time indoors or outdoors in the sun all day. Do you ever travel in a plane? Flying in a plane at a higher altitude exposes you typically to more radiation than our dental x rays do. We also take all precautions to protect you from unnecessary radiation by using the latest technology.3. Can Iget cancer fromdental x rays?Response: Going back to the discovery of xrays in the late 1800s, there has not been one proven instance of a patient getting cancer from dental x rays. And today, with our improved technol-ogy, you receive far less radiation than dental patients did back in those early days.4. Why do Ineed towear aprotective apron fordental x rays andwhy does theassistant leave theroom before taking my x rays, ifdental x rays are sosafe?Response: Our office prides itself on using whatever means we can to help reduce any unnecessary exposure both to you and to me. Our policy is: if it is simple to do, then we should do it. To protect you from x rays that may bounce off your teeth and jaws in different directions, I will place a protective apron on you, and to protect me from those same x rays, I will stand outside the room.5. Your protective apron does not have athyroid collar, why not?Response: Depending on the type of x rays we require, the collar can actually get in the way of the x‐ray beam and block the x rays making it impossible to see your teeth and jaws on the image. If that happened, then we would have to expose you again, with the collar removed. So to avoid having to re‐expose you, we leave it off when necessary. You may not realize it, but some of x rays that bounce off your teeth and bones exit your jaws through your neck. While you are wearing a thyroid collar, these x rays can actually bounce backward off the collar and expose your thyroid gland to addi-tional x rays that would have just exited your body.6. I ampregnant, should Iget dental xrays taken?Response: To be 100% safe, it is always best to avoid having any x‐ray images taken at any stage of your pregnancy. Treating your dental problem is essential to the good health of your developing baby. If you have an untreated dental infection, more harm could result to the baby than by taking a few x rays and properly treating the problematic tooth. We will take the minimum number of x rays to treat that problem and we will take all precautions to reduce the radiation exposure to you and your baby. That means, to protect your baby, I will place a protective apron on you which will absorb over 99% of the few stray x rays that might bounce off your teeth and jaws. You and your baby will be fully protected.7. When should my child first get dental x rays taken?Response: It is vital to follow the development of the baby teeth and the developing adult teeth. Every child will react differently to having dental instruments placed in their mouths. Pediatric dentists recommend first seeing children at a few years of age. At that time, a minimal number of dental x rays may be attempted to properly examine a child’s teeth. 202 Appendix 28. Will Iglow inthedark after all ofthex rays that Ireceived at thedental office?Response: Never! Dental x rays do not make people glow regardless of the exposure dose. The “glowing” that you are referring to is related to radioactive materials found in nature. X rays are not radioactive.9. What are 3‐D x rays?Response: In many dental offices today, there is a new type of sophisticated dental x‐ray unit. It is called a cone beam computed tomography (CBCT) x‐ray unit. It produces three‐dimensional views of your jaws. It does not replace our standard x rays because the images do not show fine details well, like small cavities, and it requires more radiation exposure compared with standard x‐ray images. However, it is invaluable for patients requiring dental implants. It is also used sometimes for cos-metic surgery, orthodontics, root canals and diagnosing pathology.10. Why does thedentist require additional 3‐D x rays before placing my dental implant?Response: Standard dental x rays, like panoramic x rays, only show the outer surface of the bones and teeth in two dimensions and these x‐ray images are somewhat distorted. It is not a tech-nique error but rather it is a physical problem built into that type of x‐ray equipment, which results in unavoidably distorted x rays of the teeth and bones. For successful implant placement, it is critical to have accurate images in all three dimen-sions showing the precise size and shape of the bone where the implant will be placed. CBCT provides us with this vital missing information. Cone beam images also accurately show the position of the nerve in the jaw so we can avoid damaging it when placing your dental implant. Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology203Appendix 3Helpful Tips forDifficult Patients1. Hypersensitive gag reflexA gag reflex is also termed a pharyngeal reflex or a laryngeal spasm. It is a reflexive contraction of the posterior region of the throat that includes the back of the tongue, the roof of the mouth and the tonsillar area. The gag reflex is typically triggered by tactile stimulation (i.e. physical contact). However, a patient’s hypersensitive gag reflex may be triggered by the mere sight of an intraoral x‐ray instrument. A hypersensitive gag reflex is of particular concern when per-forming intraoral imaging procedures. (Note: Some people do not have any gag reflex, possibly due to a medical condition such as vagus or glossopharyngeal nerve damage.)The maxillary molar view is often the most problematic area for patients. If multiple regions of the mouth are to be imaged, the author recommends that the operator complete all of the other areas first and then return to image the maxillary molar region at the very end. If a patient is predisposed to gagging, starting in the maxillary molar region may stress the patient so much that it may be impos-sible to continue. A consequence of this might be the inability for the operator to image the anterior region of the mouth, an area that often does not trigger a gag reflex. If a full mouth series of images is required, then the operator should wait until nearing the end of the proce-dure to casually inform the patient that only a couple of maxillary molars remain. Knowing that only one or two images remain to be taken may allow the patient to persevere and briefly permit the operator to complete the series.Most importantly, when faced with a patient having a hypersensitive gag reflex, the operator should perform the intraoral procedures as expe-ditiously as possible. That means pre‐setting the exposure time, kilovoltage and milliamperage and pre‐positioning the PID prior to inserting the receptor into the patient’s mouth. In addi-tion, only the operator should be in the room with the patient during the procedure. If other office personnel or family members are present to assist, they should be outside the operatory to avoid unnecessary delays clearing the room to permit immediate exposure once the receptor is inserted into the patient’s mouth. Time is of the essence!Utilizing the distal oblique technique might be advantageous in some cases (see Section K). Even though the distal oblique angulation will 204 Appendix 3likely overlap images of the crowns, the peria-pical areas usually will be clearly visible. The crowns can then be visualized on bitewing images. In general, if bitewing images are prescribed in addition to periapical images, it is recommended that the bitewings always be imaged at the outset. Bitewing images are well tolerated by most patients and they offer additional information that is not evident in other views.Distractions are useful ploys to counteract gagging. Instructing the patient to breathe deeply through their nose may calm and sub-due the gag reflex. Additionally, instructing the patient to raise one arm and one leg prior to inserting the receptor has also been shown to help. The patient’s need to concentrate on keep-ing an arm and a leg raised may offer enough distraction for the individual to forget about the instrumentation being placed intraorally.More tangible remedies include swabbing both the hard and soft palate with a topical analgesic. This will temporarily anaesthetize the sensitive regions and generally allow placement of the intraoral instrument properly. Similarly, gargling with a mouth rinse or sprin-kling salt on the patient’s tongue immediately prior to instrument placement may also reduce a patient’s gag reflex. If there is a trained indi-vidual in the dental office that can perform hypnosis on the patient and the patient is compliant, this may remedy a hypersensitive gag reflex to permit placement of the intraoral instrumentation.If none of the remedies discussed above work, the operator should supplement any intraoral images acquired with extraoral imaging, such as a panoramic projection. Some newer pano-ramic units also claim to offer software to cap-ture bitewing images. However the bitewing images attained with a panoramic unit will not be as diagnostic as conventional intraoral bitewing images simply due to using different geometric principles.It is important to note that if a patient is intolerant at any time during the procedure, the operator should suggest terminating the proce-dure that day and attempting again on another day. The risk to the dental practice is that a traumatized patient may decide not to return to the office for future treatment.2. Small mouth/shallow palate/constricted arch/torusSolid‐state digital receptors do not adapt well to situations where space is limited. The prob-lem here is that current receptors are rigid and are relatively bulky in size. Patients with a narrow arch, shallow palate or mandible or the presence of a torus complicate proper placement of the receptor for performing the paralleling technique. Options for the operator are limited. Using a PSP plate is preferable in these scenarios. PSP plates are thinner and are flexible, much like dental x‐ray film. Rarely will a dental practice have both solid‐state and PSP receptors because of the high financial cost. PSP systems are currently unpopular with a major-ity of dentists because of the added time and steps required for scanning the individual PSP plates. If the operator uses a solid‐state recep-tor, substituting a size 2 receptor with a smaller receptor size 1 or 0 should help. However, the operator should be aware that the smaller receptor is also shorter and that it may not be long enough to capture the length of the entire tooth on a single image. The operator should focus on the region of primary interest but take whatever images are necessary to perform a proper diagnosis.A shallow palate necessitates using the bisecting angle technique. If the operator attempts performing the paralleling technique, it will likely result in a foreshortened image caused by excessive vertical angulation of the x‐ray beam. The presence of a palatal torus in a deep palatal vault basically has the same effect as a shallow palate alone. Similarly, a shallow floor of the mouth (i.e. inadequate vertical height of the mandibular ridge) may prevent the Appendix 3 205operator from fully seating the receptor verti-cally to image the periapical region. A shallow palate and a shallow floor of the mouth are particularly common in children, simply because of incomplete growth and development. The fact is that it may be impossible to acquire diagnostic intraoral images on some patients and the practitioner must then rely strictly on extraoral images. As mentioned earlier, some panoramic units offer software to capture bite-wing images but they will not be as diagnostic as conventional intraoral bitewing images.3. Large frenulumThe lingual frenulum is a small fold of mucous membrane in the midline that extends from the floor of the mouth to the ventral surface of the tongue. A large lingual frenulum may restrict the ability of the patient to raise his or her tongue for the operator to properly position the intraoral receptor beneath it for the mandibular anterior periapical views. To counteract this problem, the operator may simply place the instrument on the dorsal surface of the tongue and have the patient fully close the jaws together. Generally, this will adequately capture the anterior periapical regions. Another option is for the operator to use the bisecting angle tech-nique. In this case, the receptor should be positioned as far lingually as possible and the angulation of the x‐ray beam can then be deter-mined using the bisecting angle formula. Positioning the receptor in the posterior regions should not be affected by the lingual frenulum (synonym: frenum).4. TrismusTrismus is a spasm of the muscles of mastica-tion that prevent the patient from opening his or her mouth appreciably. Insufficient opening of the mandible and maxilla may prevent inser-tion of the receptor instrumentation into the patient’s mouth. Extraoral imaging may be the only method for imaging the teeth if the bulki-ness of a solid‐state receptor combined with the x‐ray instrument is too large to insert. Without the convenience of extraoral imaging, the operator can remove the x‐ray instrument and position the receptor itself horizontally onto the occlusal surfaces of the teeth and perform multiple occlusal technique views to acquire some intraoral images. If a PSP plate is availa-ble, the operator may substitute a hemostat for the standard instrument. A hemostat, being less bulky, would permit sliding the receptor horizontally between the teeth and, once inside the mouth, the receptor could be flipped upright and positioned apically. Depending on the final vertical orientation of the receptor, the bisecting angle or paralleling technique can then be used by the operator.5. Cuspid superimpositionThe position of the cuspid is normally situated along the anterior curvatures of both the max-illa and the mandible. The curve of either arch forces positioning the receptor obliquely behind the cuspid. The resultant horizontal angulation invariably projects the lingual cusp of the first premolar over the distal surface of the cuspid. Consequently, superimposition of the cuspid and first premolar contacts in the cuspid view is commonplace. However, the overlapped contacts between the cuspid and first premolar should ideally be open in the premolar periapi-cal and bitewing images. One caveat here is that a solid‐state receptor may be too bulky to be positioned far enough anteriorly to capture the distal of the cuspid. The operator can com-promise by angling the receptor horizontally across the midline. This should position the receptor far enough anteriorly to capture and open the distal contact of the cuspid. However in this orientation, the horizontal angulation of the PID will likely produce some uneven magni-fication and overlapping of the two premolars. 206 Appendix 3Consequently, additional traditional premolar views would need to be imaged to complete the series.6. Rubber damDental procedures, such as endodontic or restor-ative treatments, typically involve the use of a rubber dam which will complicate intraoral receptor positioning. Regardless if the rubber dam frame is metal or plastic, it should be removed to facilitate placement of the receptor. Customized x‐ray instruments are commercially available (e.g. Endo‐Ray®) to accommodate the rubber dam, the rubber dam clamp and possible endodontic instruments. Other options may include using tongue depressors (see Figs Y12 and Y13) and hemostats. Hemostats should only be used with PSP plates and not solid‐state recep-tors. All solid‐state receptors are much thicker than PSP plates and may be damaged by tightly clamping the hemostat onto them. Generally, the bisecting angle technique must be used because the receptor cannot be positioned or maintained parallel to the tooth of interest. When necessary, patients may be requested to hold the x‐ray instrument with their own hand because it may be physically impossible to occlude the teeth together to support the instrument.7. Third molar imagingIntraoral imaging of a third molar is often challenging for even an experienced operator. In addition, it is not uncommon for an unerupted third molar to be horizontally impacted. This will further compound the difficulty level in attempting to acquire an image of the entire tooth. Gagging often becomes an issue when placing receptors far enough posteriorly to image third molars, particularly maxillary third molars. Tips for treating gagging patients are discussed earlier in this appendix and may be used with some success in this situation. Alternatively, the distal oblique intraoral tech-nique, also previously discussed, would be worth attempting. In this scenario, the recep-tor would only need to be positioned in the premolar region and then angled across the midline to capture the image. Ultimately it may be impossible to acquire an intraoral image of a third molar and an extraoral image such as a two‐dimensional panoramic projection is the alternative. Besides the procedure being more comfortable for the patient, a panoramic projec-tion will image all of the third molars simultane-ously. A CBCT may alternatively be prescribed for obtaining the three‐dimensional relation-ship of the third molars to their surrounding structures. Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology207Appendix 4Deficiencies ofX‐ray Imaging TerminologySoap bubble, honeycomb and multilocular are terms frequently used interchangeably to describe simi-lar radiologic features. Do these terms describe a single entity or are they characteristic of different osseous pathoses? The nomenclature used in den-tal radiology is confusing: the dental literature shows linguistic ambiguity and impreciseness. Descriptive terms selected to describe lesions of the jaws are often ill‐defined or may possibly be unde-fined. Although honeycomb and soap bubble are fre-quently used interchangeably to describe the same ameloblastoma, the Concise English dictionary provides different definitions for the two descrip-tors. Honeycomb is defined as a “regular arrange-ment of numerous, small, uniform compartments,” whereas soap bubble is described as “numerous, non‐uniform compartments of varying size and arranged in an irregular pattern.” Additional examples of ambiguous terminology presently in use include lace‐like, moth‐eaten, worm‐eaten, sun ray, sunburst, ground glass and cotton wool.To investigate this perceived problem in communication with current radiographic terminology, the author conducted a limited survey. The terms included in the study were cotton wool, ground glass, honeycomb, multilocular and soap bubble. Definitions for these terms were obtained from five oral and maxillofacial radiologists, an oral and maxillofacial surgeon, an attorney, two linguists and an English language professor.Survey resultsThe following definitions were supplied by the ten respondents.Cotton wool appearance (see Fig. X6)Oral and maxillofacial radiologists:1. Irregular, ill‐defined radiopaque patches2. Fluffy, rounded, opaque mass without dis-tinct margins3. Rounded radiopacities within an area of more radiolucent bone4. Numerous foci of radiopacity intermingled with areas of radiolucency5. Radiopaque globular or spherical structures with reduced numbers and thicknesses of trabeculae and haphazard or linear pattern of those that remain 208 Appendix 4Oral and maxillofacial surgeon: Like balls of cotton, fuzzy edges, centrally radiopaqueAttorney: Large, round, soft, puffy area, perhaps with soft wisps or tendrils; white or light in color relative to the backgroundLinguists:1. Composed of a mass of fluffy white threads2. Frothy white with no real shape except a general roundness; edges ill‐definedEnglish professor: Spherical fibrous mass(es)Ground glass appearance (see Fig. X3)Oral and maxillofacial radiologists:1. Fine, almost structureless granular texture; may be more or less radiopaque than normal2. Granular radiographic appearance resem-bling an orange peel or pebbled texture; variable margin patterns3. Homogeneous appearance of bone resulting from loss of contrast between trabeculae and marrow spaces4. Appearance of glass with light‐diffusing surface produced by etching or abrasion (i.e. hazy, filmy appearance); many trabeculae of bone of approximately equal size are radiographically apparent5. Resembling glass which has been pulver-ized into fine granulesOral and maxillofacial surgeon: Amorphous radiopaque appearanceAttorney: Evenly sized small compact grainsLinguists:1. Composed of tiny, hard, shiny particles2. Fairly flat and composed of small hard bits resembling granulated sugarEnglish professor: Crystalline‐appearance of chunks with hard edgesHoneycomb appearance (see Fig. X5)Oral and maxillofacial radiologists:1. Multilocular lesion with compartments smaller than those of “soap bubble” appearance2. Contiguous polygonal radiolucent regions, which may vary in border definition3. Numerous small compartments with septal arrangement resembling a honeycomb4. Similar to “multilocular” but with more linear septae5. Not used and no opinionOral and maxillofacial surgeon: Not usedAttorney: Well‐defined, roughly similar, round or squarish geometric areas branching out over relatively wide areas; separate shapes appear emptyLinguists:1. Composed of regularly joined polygons2. Framework of adjoining octagonally‐shaped hollow cellsEnglish professor: Hexagonal structuresMultilocular appearance (see Fig. X1)Oral and maxillofacial radiologists:1. Radiolucency produced by many coalescing and overlapping compartments in bone; often representative of a neoplastic or cystic process2. Radiolucency with more than one locule, having many compartments3. Usually pathologic well‐corticated radiolu-cencies; internal septae, total or partially separate compartments (in two‐dimensions) within the boundaries of the lesion4. Radiolucent lesion with two or more round or ovoid compartments which appear to be Appendix 4 209partially separated from one another by incomplete septae5. Having many compartmentsOral and maxillofacial surgeon: Multicystic or soap bubble appearanceAttorney: Many circles in a well‐defined areaLinguists:1. Unknown2. UnknownEnglish professor: Spheres or ovals within a larger bodySoap bubble appearance (see Fig. X1)Oral and maxillofacial radiologists:1. Multilocular lesion consisting of several circular compartments which vary in size and usually appear to be somewhat overlapped2. Multilocular radiolucency with many loc-ules varying in size from large to very small3. Radiolucent compartments of variable size, faint septae and poorly defined borders4. Similar to “multilocular” but with more rounded septae5. Similar to “multilocular” but with many loculations; reminiscent of soap bubbles; bony septae between locules are very fine whereas in “multilocular” lesions the septae can be coarseOral and maxillofacial surgeon: Multilocular with compartments of varying sizeAttorney: Many small spheres clustered together; light density, puffy and soft, and empty or clear in appearanceLinguists:1. Composed of mass of iridescent spheres of numerous sizes2. Large shiny balls, each ball or sphere impinging on and partially adhering to other balls or spheresEnglish professor: Cluster of spherical masses with flat adjoining surfaces (i.e. with mutual walls)Examination of the definitions just listed shows the discrepancies in the respondents’ percep-tions. Hence it is apparent that terms currently used by dental professionals to describe x‐ray images are ambiguous. Interpretation is based on individuals’ own conceptions and past edu-cation. Such impreciseness could lead to a gap in communication of significance to patient treatment and outcome.Gill et al. (1973) evaluated observer variations in history taking and physical examination. He found disagreement was significantly reduced when a common set of definitions was devel-oped and used by the participating physicians. It is suggested that a standardized set of definitions of radiographic features, if formulated, could reduce the margin of error currently resulting from subjective interpretation and definitional variability among dental diagnosticians. Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology210Appendix 5Tools forDifferential DiagnosisThere are seven criteria useful for describing osseous lesions to formulate a differential diagnosis:1. Number2. Location3. Density4. Shape5. Size6. Borders7. Changes to surrounding anatomic struc-tures such as root resorption and tooth displacementNote: Each criterion listed above has limited value on its own, but a combination of all seven can significantly improve the differen-tial diagnosis. Ultimately a biopsy of the lesion may still be required to confirm the diagnosis.1. NumberHow many anomalies are present? Excluding tooth‐specific pathology (e.g. caries) and gen-eralized pathology (e.g. metabolic disease) that may encompass one or both dental arches entirely, the vast majority of osseous lesions appear single in number. Consequently, when a couple or more lesions are observed, it can assist the clinician in narrowing down the differential diagnosis. For example, bilateral radiolucencies in the rami of young individuals are very characteristic for cherubism.2. LocationWhere is the anomaly located? Is it in a tooth‐bearing region or a non‐tooth‐bearing region? This information can help to differentiate odontogenic versus non‐odontogenic pathol-ogy from the diagnosis. Many types of osseous pathology characteristically occur in one region of the mandible or maxilla. However, with the paucity of cases reported in the dental litera-ture for some types of pathology, one must not eliminate an entity because it is located in a non‐characteristic region of the facial complex. Location often helps to rank diagnoses higher or lower in the differential depending on whether it is found within or outside of its typical region. Appendix 5 2113. DensityIs the anomaly radiolucent, radiopaque or mixed (i.e. combination of radiolucent and radiopaque)? Density is invaluable for dis-cerning the composition of the anomaly. Radiolucent areas typically indicate a destruc-tive process within the area in question. Excluding an air space, radiolucent areas will be composed of soft tissue, fluids or a combination of the two. A radiopaque area typically indicates a calcifying (i.e. ossifying) process. A mixed radiolucent and radiopaque region may be either a destructive process or a calcifying process. For example, osteomyelitis is an infection leading to destruction of bone. While an ossifying fibroma is a calcifying pro-cess that may show both radiopaque and radi-olucent regions during its intermediate stage of development. Interestingly, one must be cognizant about soft tissue and fluids located within more radiolucent areas of the orofacial complex (e.g. sinus). Contrary to what one would expect, in this situation soft tissue and fluids will not appear radiolucent but rather will have a somewhat radiopaque appearance. The reason is that soft tissue and fluids will attenuate additional radiation, giving it a radiopaque appearance relative to a less dense surrounding region. If the same soft tissue or fluid was located within a more opaque region like the ramus, it would typically appear radi-olucent. Density is the most important finding for deriving a differential diagnosis.4. ShapeIs the area in question, for example, round, elliptical, square or amorphous? Quite often, shape is used to characteristically describe the typical appearance of a particular disease process. Soap bubble appearance is often asso-ciated with an ameloblastoma; honeycomb appearance is often associated with a myxoma; sunburst appearance is associated with an osteosarcoma, etc. The problem is that these radiologic terms are rarely defined in publica-tions, leaving the interpretation up to the observer. More importantly, these appearances often only appear in the late stages of disease development. As a result, observing an earlier stage of disease development, the lesion may appear very different and the clinician may incorrectly discard that disease entity from the differential diagnosis because it did not have the classic radiologic appearance.Shape indirectly can assist the clinician in assessing the consistency of the lesion. A round radiolucency would be more indicative of a fluid core. The dynamics of a round‐shaped radiolu-cency is similar to a balloon. As the balloon inflates and as the radiolucency enlarges, they expand evenly in all directions. Of course shape exceptions will occur when an enlarging radio-lucent area encounters an obstacle, e.g. a root of a tooth. The obstacle can act as a barrier and force the expanding lesion to detour around it, thus altering the symmetric shape. Conversely, an irregular‐shaped radiolucency not modified by other structures might be more indicative of a soft tissue composition. Similar to flowers bud-ding on a stem of a plant, a soft tissue lesion may bud out in different directions.5. SizeHow large is the area of concern? Size can be a general indicator of the period of time the lesion has been developing. One would generally expect that a larger lesion would have required a longer period of time to grow. A large lesion could also imply that it is benign in nature, particularly if it is painless. If the lesion was painful, it is more likely that the patient would have sought treatment earlier when the lesion was smaller in size. A great deal of weight should not be applied to this interpretation (i.e. benign versus malignant), but combined with all the other findings, it may help to modify the differential diagnosis. 212 Appendix 5For the differential diagnosis, size does not have to be 100% accurate. However, descriptive terms such as large, big and small are all too subjective and as a result should not be used by clinicians. Each person may interpret these terms very differently. If you are consulting with another clinician over the telephone about a case, it is best to describe the size of the area using either an approximate numeric measurement or simply comparing its size to a commonly known object (e.g. size of a dime) that others will be familiar with. This will better assist the other clinician to mentally envision the lesion.6. BordersIs the area well-demarcated, does it have a corticated border, is it difficult to differentiate abnormal from normal tissue? Well‐defined borders are typically indicative of a slower growing, non‐malignant lesion versus an ill‐defined lesion. An ill‐defined lesion would be more indicative of an aggressive, possibly malignant lesion. Well‐corticated borders are indicative of the body’s attempt at curtailing the lesion’s growth; in essence the body’s defense is attempting to wall it off. Aggressive, rapidly growing lesions will not be easily con-tained, will spread around obstacles (e.g. teeth) and will often appear with ill‐defined borders. Be certain not to confuse ill‐defined borders with poor diagnostic quality x‐ray images.7. Changes tosurrounding anatomic structuresRadiographic changes such as expansion of the cortical plate, root resorption and tooth displacement are useful for determining the behavior of the lesion. Expansion of the cortical plate versus destruction of it is indicative of a slower‐growing, less aggressive lesion. Root resorption is indicative of a slower‐growing or long‐standing lesion because of the time it would take to cause destruction of a solid tooth structure. Pathologic tooth dis-placement, like orthodontic tooth movement, is not a quick process. It would indicate a slower‐growing lesion. A rapidly growing lesion would quickly spread around the tooth. Consequently, changes to normal anatomic structures are worth noting to help ascertain the behavior of the lesion in question.In conclusion, combining all of the informa-tion from the seven criteria discussed above will give the clinician a significant amount of information to help construct a concise differ-ential diagnosis. This is especially critical in aprivate practice scenario when the clini cian has a patient who presents with some unknown oral pathology. The practice may not have advanced imaging modalities like CBCT or have a pathologist’s biopsy report at the initial visit. Yet the patient expects some information about the seriousness of the situation before departing the dental office. Fortunately, the clinician can dissect signifi-cant amounts of information from conven-tional x‐ray images and combine that with information derived from the medical history and dental exam to give the patient an intelli-gent answer as to the behavior of the lesion and how to proceed. It may or may not be enough information to accurately diagnose the lesion but at least the behavior of the pathosis should be evident. Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology213Appendix 6Table ofRadiation UnitsTraditional units SI units ConversionRoentgen (R) Coulombs per kilogram (C/kg) 2.58 × 10–4 C/kg = 1 RRadiation absorbed dose (rad) Gray (Gy) 1 Gy = 100 radRoentgen equivalent man (rem) Sievert (Sv) 1 Sv = 100 rem Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology214Appendix 7Table ofAnatomic LandmarksTooth• Dentin• Cementum• Enamel• PulpTooth‐related structures• Alveolar bone (cancellous and cortical bone)• Alveolar crest• Lamina dura• Periodontal ligament spaceLandmarks associated withthemaxillaRadiopaque• Anterior nasal spine• Hamular process• Nasal concha• Nasolabial fold• Nose (soft tissue)• Pterygoid plates• Torus (aka palatine torus, torus palatinus;pl.tori)• Zygoma and zygomatic processRadiolucent• Incisive foramen• Lateral fossa• Lip line• Maxillary sinus• Mid‐palatine suture (aka intermaxillary suture)• Nasal fossa• Nasolacrimal canalLandmarks associated with the mandibleRadiopaque• Coronoid process• Genial tubercles Appendix 7 215• Inferior border of the mandible• Lip line (soft tissue)• Mental ridge (aka mental process)• Oblique ridge, external• Oblique ridge, internal• Torus (aka mandibular torus, torus mandibularis; pl. tori)Radiolucent• Lingual foramen• Mandibular canal• Mental foramen• Mental fossa• Nutrient canals• Submandibular gland fossa Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology216Appendix 8Table ofDental AnomaliesNumber• Anodontia• Oligodontia• Supernumerary toothSize• Macrodontia• MicrodontiaShape• Concrescence• Dens evaginatus• Dens invaginatus• Denticle• Dentinal bridge• Dilaceration• Enamel pearl• Fusion• Gemination• Hutchinson’s incisor• Hypercementosis• Mulberry molar• Taurodont tooth• Turner’s toothDevelopmental defects• Dysplasia, dentin• Hypoplasia, enamel• Imperfecta, amelogenesis• Imperfecta, dentinogenesis• Imperfecta, osteogenesis• Odontodysplasia, regional• Pulpal obliterationEnvironmental effects• Abrasion• Ankylosis• Attrition• Calculus• Caries, dental• Caries, radiation• Erosion• Foreign body• Fracture• Impaction• Resorption, external• Resorption, internal• Restorations• Rotation• Transposition Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc. Companion website: www.wiley.com/go/hubar/radiology217Appendix 9Table ofOsseous PathologyRadiolucent anomalies inthemaxilla andmandible• Abscess, periapical• Ameloblastoma• Bone marrow defect• Calcifying epithelial odontogenic tumor (early stage)• Cherubism• Cysts: – aneurysmal bone – botryoid – calcifying odontogenic – dentigerous – incisive canal – lateral periodontal – median palatine – nasopalatine – odontogenic keratocyst (see keratinizing odontogenic tumor) – periapical (radicular) – residual – Stafne bone – traumatic bone• Fibrosarcoma• Fibrous dysplasia (early stage)• Florid osseous dysplasia (early stage)• Giant cell granuloma• Giant cell tumor• Granuloma, periapical• Hemangioma• Hyperparathyroidism• Keratinizing odontogenic tumor• Metastatic tumor• Multiple myeloma• Myxoma• Osseous dysplasia (early stage)• Ossifying fibroma (early stage)• Osteoporosis• Salivary gland tumors, benign and malignant• Scar, periapicalRadiopaque anomalies inthemaxilla andmandible• Antrolith (located within a sinus)• Calcifying epithelial odontogenic tumor (late stage)• Cementoblastoma• Condensing osteitis• Enostosis• Exostosis• Fibrous dysplasia (late stage)• Florid osseous dysplasia (late stage) 218 Appendix 9• Foreign body• Odontoma: complex, compound• Osseous dysplasia (late stage)• Ossifying fibroma (late stage)• Osteopetrosis• Phleboliths, intraoral• Torus: palatine, mandibularMixed (radiolucent–radiopaque) anomalies inthemaxilla andmandible• Calcifying epithelial odontogenic cyst• Calcifying epithelial odontogenic tumor (intermediate stage)• Condensing osteitis• Fibrosarcoma (intermediate stage)• Fibrous dysplasia (intermediate stage)• Osseous dysplasia (intermediate stage)• Ossifying fibroma (intermediate stage)• Osteomyelitis• Osteosarcoma• Paget’s disease• Periapical osseous dysplasia (intermediate stage) 219Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.Companion website: www.wiley.com/go/hubar/radiologyAppendix 10Common Abbreviations andAcronyms is the universal symbol for radiation that is posted in public areas where there is ionizing radiation in the immediate vicinity.A amp/amperageADA American Dental AssociationAIDS acquired immunodeficiency syndromeALADA as low as diagnostically acceptableALARA as low as reasonably achievableBID beam indicating deviceBOC botryoid odontogenic cystBW bitewingCBCT cone beam computed tomographyCCD charge coupled deviceCDC Centers for Disease Control and PreventionCEOT calcifying epithelial odontogenic tumorcm centimeterCMOS complementary metal oxide semiconductorCMX complete mouth series of x raysCOC calcifying odontogenic cystCT computed tomographyDHCP dental healthcare practitionerDICOM digital imaging and communications in medicineEM electromagneticEPA Environmental Protection AgencyFDA Food and Drug AdministrationFMS or FMX full mouth series of x raysFOV field of viewGy grayHBV hepatitis B virusHIPAA Health Information Portability and Accountability ActHIV human immunodeficiency virusHVL half value layerHz hertzICRP International Commission on Radiological Protectionkerma kinetic energy released per unit mass 220 Appendix 10kV kilovolt/kilovoltagekVp kilovolt peakLPC lateral periodontal cystmA milliamp/milliamperagemAs milliampere secondsMPD maximum permissible doseMPR multiplanar reconstructionMRI magnetic resonance imagingmSv millisievertNCRP National Council on Radiation Protection and Measurementsnm nanometerOSHA Occupational Safety and Health AdministrationPA periapical image or the anteroposterior direction of an x‐ray beamPDL periodontal ligamentPID position indicating devicePPE personal protection equipmentPSP photostimulable phosphorQA quality assuranceR roentgenrad radiation absorbed doserem radiation or roentgen equivalent manRHI receptor holding instrumentSI Système Internationale or international system of unitsSLOB same–lingual, opposite–buccalTMD temporomandibular joint dysfunctionSv sievertV volt/voltage 221Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.Companion website: www.wiley.com/go/hubar/radiologyAppendix 11Glossary ofTermsAbrasion: the pathologic wearing of a tooth structure by mechanical means.Absent crown: a tooth lacking its entire crown; the presence of roots only (e.g. radiation caries can preclude total crown destruction).Absorption, x‐ray: the attenuation of x‐ray photon energy as it passes through a material.ALADA: an acronym meaning “as low as diag-nostically acceptable.” The intent of this updated ALARA principle is for the operator to use a minimal dose of radiation exposure and still acquire a diagnostic image.ALARA: an acronym meaning “as low as reasonably achievable.” The intent of this principle is for the operator to employ all reasonable measures to minimize a patient’s exposure to radiation (e.g. use of a protective apron).Alpha radiation: a form of particulate radia-tion emitted from heavy metals. It contains two protons and two neutrons identical to a helium nucleus. It is not able to penetrate skin.Alveolar bone: the bone that comprises both the maxilla and the mandible. It surrounds the roots of teeth. The alveolar process is the spe-cific region of bone that surrounds the roots of teeth and the sockets of missing teeth.Amalgam: an alloy of metals which include mercury, silver, tin and copper. It has largely been replaced with non‐metallic composite materials today. Amalgam restorations appear very radiopaque on dental images.Ampere: represents the amount of current flowing in a circuit. One milliampere (mA) is one‐thousandth of an amp. It primarily con-trols the quantity of radiation produced. Higher amperage results in a higher output of radiation from the x‐ray tubehead.Analog: x‐ray film is considered to be an analog format. When the film, which is a poly-ester‐base coated with a photosensitive emul-sion, is exposed to radiation, it creates an analog image of an area of the dentition. Digital has largely replaced film as an image recording format. 222 Appendix 11Angled root: a marked angulation of a root of a tooth in relation to its crown. Synonym: dilaceration.Angström (Å): a unit of measure equaling one ten‐billionth of a meter (10–10 m).Angulation, horizontal: the side to side aim-ing direction of the PID. Proper horizontal angle is critical for exposing good bitewing images. Aiming the x‐ray beam between adja-cent tooth contacts is considered proper hori-zontal angulation. This should produce dental images with little or no overlap of interproxi-mal contacts, which is important for diagnosing caries.Angulation, vertical: the up and down aiming direction of the PID. Excessive vertical angula-tion (i.e. overangulation) will result in a fore-shortened image, while insufficient vertical angulation (i.e. underangulation) will produce elongation of the image.Anode: consists of a copper tube and a small tungsten focal spot. It is the positively‐charged target end of the x‐ray tube. High‐speed electrons from the cathode strike the anode and produce quantities of x‐ray photons.Anodontia: the complete absence of all teeth is called total anodontia, while partial anodontia is the absence of some teeth.Anterior loop of the mandibular canal: the mandibular canal forms the anterior loop by extending anteriorly beyond the mental fora-men and then turning posteriorly to reach the mental foramen.Anterior nasal spine: a small bony projec-tion of the maxilla at the anterior aspect of the mid‐palatine suture (i.e. anteroinferior aspect of the nasal cavity). It is often used as an orthodontic landmark on cephalographic images.Antiseptic: an antimicrobial substance for reducing the potential for infection.Aplasia: the congenital absence or abnormal development of a structure.Atomic number: the number of protons within the nucleus of an atom.Attenuation: the reduction in the intensity of the x‐ray beam.Attrition: the pathologic wearing down of a tooth structure by tooth to tooth contact.Autoclaving: the use of high‐pressure saturated steam to sterilize equipment.Axial plane: an imaginary line that divides the patient’s head into superior and inferior parts. It is perpendicular to the coronal and sagittal planes. Clinicians routinely view CBCT images in this perspective.Background radiation: the ubiquitous environ-mental radiation that all people are exposed to on a daily basis. It includes both natural and arti-ficial sources (e.g. cosmic rays, radon gas, nuclear fallout, occupational exposure). Background radiation levels will vary geographically depending on altitude and soil composition.Barrier, protective: a physical mechanism to protect a patient or operator from contact with potentially infective substances such as blood and saliva. A physical shield is for the operator to stand behind for protection from stray x rays. A barrier envelope is a disposable plastic cover that slips over a dental receptor.Beta radiation: beta particles are electron particles emitted from a nucleus; particulate radiation is unlike electromagnetic radiation, which has no mass.BID: the acronym for beam indicating device. (See PID.)Bifid canal: the presence of a second man-dibular canal running parallel to the primary mandibular canal. It houses smaller accessory branches of the inferior alveolar nerve. A bifid canal is more commonly seen in panoramic and CBCT images. Appendix 11 223Bisect: divide into two equal size sections.Bisecting angle technique: an intraoral imag-ing technique in which the operator bisects the angle formed by the long dimension of the tooth and the position of the receptor. The cen-tral x‐ray beam is then aimed perpendicular to that imaginary line referred to as a bisector.Bisphosphonates: a category of drugs pre-scribed for slowing down or preventing bone loss. They are commonly used to treat osteo-porosis and cancers that affect bone mass (e.g. lung, breast and prostate tumors). Performing invasive dental procedures such as an extrac-tion, an implant placement or endodontic sur-gery on a patient receiving long‐term intravenously administered bisphosphonates has been linked to osteoradionecrosis. Diabetes has also been associated with bispho-sphonate osteonecrosis .Bitewing image: an intraoral image that shows both the mandibular and maxillary crowns in one image. It is useful for diagnosing interprox-imal dental caries and alveolar bone height. Orientation of the long dimension of the image receptor sideways is referred to as a horizontal bitewing; orientation of the long dimension of the receptor upright is referred to as a vertical bitewing. Vertical bitewings are often preferred by periodontists to image more of the alveolar bone surrounding the teeth.Bitewing tab: a simple intraoral receptor hold-ing device usually made of paper or plastic for a patient to bite upon. It functions to secure the receptor in position for bitewing images. This allows the operator more flexibility in deter-mining the correct horizontal angulation for avoiding overlapped interproximal contacts. It is particularly beneficial when there is tooth rotation or crowding present.Botryoid: appearing like a cluster of grapes (e.g. botryoid odontogenic cyst).Bregma: commonly referred to as the soft spot on the top of a newborn baby’s head. It is the landmark on the skull where the sagittal and coronal sutures join and the parietal and fron-tal bones come together.Bremsstrahlung radiation: a German term meaning braking rays. Bremsstrahlung radiation occurs when electrons collide with the anode in an x‐ray tube. Virtually all x rays produced within the range of kilovoltage used in dental x‐ray units are bremsstrahlung x rays. More powerful medical x‐ray generators can addi-tionally produce characteristic radiation.Brightness: a measure of intensity after the image has been acquired.Burnout: see Cervical burnout.Bus, computer: a pathway that a computer uses to transfer data.Café au lait spots: flat pigmented spots on the skin, the color of coffee with milk, com-monly associated with fibrous dysplasia and neurofibromatosis.Caries: see Dental caries.Cathode: the negatively‐charged end contain-ing a tungsten filament within a dental x‐ray tube. Heating the filament releases a cloud of electrons that can be accelerated across the tube to the anode to generate x rays.CBCT: see cone beam computed tomography.CCD (charge coupled device): a solid‐state digital image receptor introduced into dentistry in 1987; basically it consists of a silicon wafer coated with a scintillation layer which increases the efficiency of x‐ray absorption.Central ray: for directional purposes, this refers to the x‐ray stream that is located at the center of the beam as it exits from the PID.Cephalograph: a lateral x‐ray image of the skull showing both the bony and soft tissue structures. A head‐positioning device referred to as a cephalostat is used for standardization and reproducibility. A cephalograph is typically 224 Appendix 11used in orthodontic treatment to assess facial growth.Cephalostat: a head‐holding attachment on extraoral x‐ray units for acquiring cephalo-graph images.Cervical burnout: an illusionary radiolucency along the neck (i.e. cervical region) of the tooth caused by differential x‐ray absorption. The dentin in the crown of the tooth is encap-sulated with enamel; the dentin and cemen-tum in the root of the tooth is surrounded by alveolar bone; the cervical region between the two is limited to only dentin and cementum. Consequently, more x rays penetrate through the cervical area, giving it a more radiolucent appearance compared to the encapsulated crown or the root embedded within bone. Cervical burnout can form a radiolucent band extending mesio‐distally across the entire tooth or it may be localized to smaller areas in the mesial and/or distal surfaces along the neck of the tooth. It should not be misdiagnosed as dental caries.Characteristic radiation: radiation that is produced when an electron is ejected from its orbit and another electron takes its place by dropping down from a higher shell. Dental x‐ray units, unlike medical x‐ray units, typi-cally will not generate a kilovoltage great enough to produce characteristic radiation.CMOS (complementary metal oxide semi-conductor): a solid‐state direct digital image receptor incorporating silicon based semicon-ductors. CMOS differs from CCD technology in how the charges produced by the absorbed x‐ray photons are read. It is widely used in the manufacture of computer processing chips.Collimation/collimator: All dental x‐ray tubeheads contain a lead collimator to regulate the size and shape of an x‐ray beam. A collima-tor is the device that will produce either a round or rectangular‐shaped x‐ray beam. The National Council on Radiation Protection and Measurements recommends using rectangular collimation. An advantage of rectangular colli-mation is an additional reduction in patient exposure compared to using round collimation. It is possible to convert a round beam into a rectangular collimated beam. A rectangular collimator can be attached to either the open end of a round PID or directly onto a receptor instrument itself. Regardless of the beam shape, beam size is government regulated. The maxi-mum allowable size of an x‐ray beam at the patient’s face is 7 cm.Complete dentition: the presence of a full complement of teeth.Complete mouth series (CMX): see Full mouth series.Compton scatter: this occurs when an incoming x‐ray photon knocks out an orbiting electron from an outer shell of an atom. The net result is a positively charged atom and a free electron. The incoming x‐ray photon gives up some of its energy and is redirected (i.e. scattered). The ejection of the electron from its orbit is referred to as ionization and the radiation itself is classi-fied as ionizing radiation.Concha: a horizontal outgrowth on the lateral wall of the nasal fossa. The nasal fossa has infe-rior, medial and superior conchae bilaterally. Synonym: turbinate.Cone beam computed tomography (CBCT): CBCT technology was first introduced in 1996. Similar to a panoramic x‐ray unit, a CBCT scan-ner rotates around the patient’s head. However, unlike a panoramic unit, a CBCT unit acquires upwards of 600 individual images using a cone‐shaped beam of x radiation. The acquired data is then reconstructed by a computer algorithm into axial, sagittal and coronal planar images.Cone‐cut: an intraoral technique error produced when an x‐ray beam and a receptor are not prop-erly matched with each other. The cone‐cut is the blank area on the image that corresponds to the receptor area that was unexposed. Appendix 11 225Conical: tapered; narrowing to a point.Constricted: narrowed.Contact, interproximal: refers to the contact-ing surfaces of two adjacent teeth. Bitewing images are intended to open adjacent tooth surfaces to primarily reveal the presence of caries. When adjacent tooth surfaces are superimposed upon one another, they are referred to as overlapped contacts. Incorrect horizontal angulation of the PID generally is the cause of overlapped contacts.Contralateral side: affecting or occurring on the opposite side.Contrast: refers to the degree of gray scale (i.e. number of shades of gray) differentiation that exists on an x‐ray image. High‐contrast images display fewer shades of gray than those of lower contrast. High‐contrast images are better for visualizing dental caries, while low‐contrast images are better for diagnosing periodontal conditions, such as crestal bone height. High contrast may be referred to as a short‐scale contrast and low contrast is referred to as a long‐scale contrast.Coronal plane: a vertical plane that divides the body into anterior and posterior sections. Synonym: frontal plane.Cortical plate, mandibular: the outer layer of compact bone that overlies the spongiosa bone of the alveolar process. It generally appears as a thin radiopaque line on x‐ray images. Thinning of the cortical plates occurs naturally with age, but extreme thinning may also be the result of a metabolic disorder such as osteoporosis.Cotton wool appearance: the alteration in tra-beculae resulting in irregular patches of bone with increased density and diffuse borders resembling mycelium. These patchy areas, within which it is impossible to see any nor-mal anatomic structures, may be a few millim-eters to several centimeters in diameter. (See Fig. X6.)Coulomb per kilogram (C/kg): the SI unit for ionizing radiation exposure. It is a measure of the amount of radiation required to create 1 C of charge in 1 kg of matter; 1 C/kg = 3875.96899224806 roentgen.Crookes–Hittorf tube: a partially evacuated electrical discharge glass tube containing a cathode and an anode that can produce x‐radiation when high voltage is applied to it. It was used by Professor Wilhelm Röntgen in 1895 when he discovered x rays. Modern vac-uum x‐ray tubes contain a heated filament (i.e. cathode) that release electrons.Curve of Spee: the natural curvature of the mandibular occlusal plane beginning at the tip of the cuspid and continuing along the cusps of the posterior teeth.Dead space, receptor: the inactive peripheral portion of a solid‐state intraoral receptor that cannot capture an image.Dens evaginatus: an enamel‐covered tubercle that projects from the occlusal surface of an oth-erwise normal tooth. There is no age or sex pre-dilection. The tubercle appears as a small, round radiopacity having the same density as enamel. Clinically, the evagination varies from one to several millimeters in size. The patient often pre-sents with malocclusion and occlusal trauma.Dens invaginatus: a developmental anomaly believed to arise from an invagination in the surface of the crown of a permanent tooth before calcification has occurred. The maxillary lateral incisors are most frequently affected. It often appears · as a pear‐shaped radiolucent invagination lined with a thin layer of enamel and dentin that projects into the pulp. Synonym: dens in dente.Density, image: the degree of darkness of an image. The brightness control in digital soft-ware programs controls image density.Dental caries: demineralization of a calcified tooth structure results in the formation of 226 Appendix 11aradiolucent area on an x‐ray image. Synonyms: cavity or tooth decay.Denticle: a round- or oval-shaped calcified body within a pulp chamber of either a perma-nent or deciduous tooth.Dermatitis: a general term describing inflam-mation of the skin. It typically is a response to radiotherapy.Deterministic effects: a minimum threshold dose of radiation exposure has to be surpassed for an effect to be observed. Severity of the effect is dose dependent. The higher the radiation dose received, the greater is the effect. Examples include erythema, epilation (i.e. hair loss), cataracts, etc. Synonym: non‐stochastic effects. (See Stochastic effects.)Diabetes mellitus, radiologic: uncontrolled diabetic patients often exhibit periodontal dis-ease. In addition, diabetes may be a riskfactor for developing bisphosphonate osteonecrosis.DICOM (Digital Imaging and Communi cations in Medicine): a standard for handling, storing and transmitting information in digital images universally. DICOM includes a file format and a network communications protocol. These files can be exchanged between two entities that are capable of receiving image and patient data in a DICOM format.Dilaceration: an angular distortion in the root or crown of a formed tooth. As a result, the tooth appears bent or twisted.Direct digital receptor: an acquired image sent directly to a computer either via a wired receptor or via Wi‐Fi transmission. Typically the receptor uses either CMOS or CCD technologies.Disinfection: to destroy or inhibit the growth of pathogenic microorganisms by physical or chemical means.Distortion, image: an exaggeration in the size and/or shape of an object on an x‐ray image. A proper paralleling technique minimizes both size and shape distortion of intraoral images.Dosimetry badge: a badge worn for recording cumulative x‐radiation dose to personnel in the workplace. Government regulates occupa-tional radiation exposure limits. Multiple companies offer monitoring services for den-tal office personnel for nominal fees. Synonym: dosimeter.Duty cycle: the recommended time delay between x‐ray exposures. Proper cooling of the x‐ray tube is necessary to prolong the life expec-tancy of the x‐ray tube. The life of the x‐ray tube will be shortened if it is unable to cool down properly between exposures. Manufacturers of dental x‐ray units provide duty cycle informa-tion for comparison shopping.Ectodermal dysplasia: a group of genetic dis-orders of ectodermal structures. There may be abnormal development of the hair, teeth, nails and sweat glands.Ectopic location: any tooth or object that is in an abnormal position.Edentulous: the absence of one or more teeth.Effective dose: the dose of ionizing radiation used to determine the probability of inducing genetic effects and cancer. It also allows the comparison of the effects of different types of radiation upon different types of tissues. The unit of effective dose is the sievert. Effective dose equivalent was shortened to “effective dose” in 1991.Eggshell appearance: a thin, radiopaque, lamina‐dura like layer of bone circumscribing either an oval‐shaped radiolucent area or a radiolucent border around a radiopaque lesion.Electromagnetic radiation: a form of energy that travels in wave form and has no mass. Examples include x rays, visible light, radio waves and microwaves.Electron: a subatomic particle with a negative charge.Electron cloud: the area around the heated cathode filament in an x‐ray tube where free Appendix 11 227electrons congregate. Powering on an x‐ray unit sends a low voltage current to the cathode of the x‐ray tube. The filament heats up and emits electrons which remain at the cathode until the operator presses the exposure button. Depressing the exposure button sends a high voltage across the x‐ray tube. This causes an acceleration of the electrons across to the anode and the generation of x‐ray photons.Elongation, image: an elongated object is dis-torted and appears longer on an x‐ray image than it is clinically. Vertical underangulation of the PID or a physical curving (i.e. bending) a PSP plate when it is positioned intraorally will cause image elongation.Embedded tooth: an unerupted tooth that is not prevented from normal eruption by an obstruction.Erosion: the pathologic wearing down of tooth structure by chemical means.Erythema: a superficial reddening of the skin.Erythema dose: the radiation dose required to produce a redness of the skin. It generally occurs after exposure to 250 centisieverts (cSv) of radiation that is delivered in a relatively short span of 14 days. For comparison pur-poses, exposure doses from dental imaging are typically in microsieverts (mSv).Evaginated crown: an abnormal protuberance on a crown.Exostosis (pl exostoses): a benign self‐limiting production of new bone that protrudes from the surface of an existing bone (e.g. osteoma, torus).Exposure time: the duration of radiation generation. Modern intraoral x‐ray units have exposure settings ranging from hundredths of a second to multiple seconds in length.Extraoral: located outside of the mouth.Extraoral image: an image acquired when the image receptor is positioned outside of the patient’s mouth. Extraoral dental projections include panoramic, cephalometric and CBCT imaging.Fetal badge: a radiation dosimeter for a preg-nant worker used to monitor radiation dose to the fetus over the term of the pregnancy.Field of view (FOV): regarding CBCT images, it refers to the collimated area that is being imaged.Film, non‐screen: all intraoral dental x‐ray film is classified as non‐screen film because it does not use an intensifying screen. If an incoming x‐ray photon collides with one of the silver halide crystals in the film emulsion, then it will precipi-tate out as a silver atom during chemical pro-cessing. As a result, a non‐screen film requires more radiation to produce an image compared to screen film but it will produce a compara-tively higher resolution image. Synonym: direct exposure film.Film, screen: all extraoral dental x‐ray film types are categorized as screen film. Unlike non‐screen film, this category of film must be manu-ally loaded into a film cassette. Each cassette will contain a pair of intensifying screens that surround the film on both the front and back sides. An intensifying screen contains rare earth minerals and phosphor materials that convert incoming x‐ray photons into visible light. The emitted light from the screen exposes multiple silver halide crystals in the film’s emulsion. Consequently there is a reduction in the total number of x‐ray photons required to produce an image but it also lowers the image resolution compared to non‐screen film images. Synonym: indirect exposure film.Film, x‐ray: this is composed of a polyester base that is coated with an emulsion. The film emulsion is a mixture of silver halide crystals embedded within a gelatin base. A developed piece of x‐ray film is referred to as a radiograph. The dental radiographs are typically inserted into a film mount to secure them and then they are viewed on a lighted view box or a light box. 228 Appendix 11For many years, x‐ray film was the standard for recording dental images. Today, it has largely been replaced by digital imaging receptors.Filter, x‐ray: typically a 1.5–2.5 mm thick sheet of aluminum built into all dental x‐ray tubeheads. It is used to absorb (i.e. block) low energy x‐ray photons before they can exit the x‐ray unit. Filtering removes low energy x‐ray photons that will not be able to penetrate through a patient’s tissues to expose the image receptor. These low energy x‐ray pho-tons are of no benefit to either the operator or patient.Flat panel detector: a solid‐state digital x‐ray receptor commonly used in CBCT x‐ray units. It may be either an indirect or a direct receptor.Floating tooth: a root of a tooth that is com-pletely surrounded by a radiolucent area. It exhibits a complete absence of both the lamina dura and the immediate surrounding alveolar bone.Focal spot: the tungsten target of the anode inside an x‐ray tube. It is the location where the accelerated electrons emanating from the cath-ode are directed. The focal spot is where x‐ray photons are generated.Focal trough: an invisible three‐dimensional zone specific for each extraoral x‐ray unit. Laser lights on the x‐ray unit are typically used to assist the operator in positioning the patient. Alignment of the patient by the operator in the focal trough will most accurately reproduce structures such as the mandible and maxilla. An operator’s failure to properly position the patient in the focal trough will result in distor-tion and an overall decrease in the quality of the image.Fog, image: an undesirable darkening of an image that produces a loss of image contrast. It is typically caused by scatter radiation. Fogging produced by light leakage is unique to x‐ray film; light from an external light source exposes the unprocessed film.Foreign body: any object or material that is not normal for the area in which it is located.Foreshortened, image: vertical overangulation of an x‐ray beam will distort the image of an object, making the object appear shorter on a dental image than its true length.Frenulum: a small fold of mucous membrane that secures or restricts the movement of a mobile structure (e.g. tongue, lip). Synonym: frenum.Full mouth series (FMS or FMX): a series of intraoral periapical and bitewing images that show all of the edentulous and edentulous areas of the mouth. The total number of images in an FMX is variable; it depends upon the size of the mandible and the maxilla, the number of teeth, etc. A typical FMX requires 15–20 indi-vidual images. Synonym: complete mouth series (CMX).Generalized bone lesion: a lesion involving an entire bony structure.Genetic effects of radiation: the effects of radi-ation on the germ cells. Changes produced in the genes and chromosomes of the germ cells may affect future offspring of the exposed individuals.Germ cells: the oocytes and the spermatocytes. They are also sometimes referred to as genetic cells or reproductive cells. These cell types differ from somatic cells which comprise all of the other tissue cell types. The effects of radiation differ between germ and somatic cells.Gestalt: can simply be described as seeing the whole picture.Ghost image: a faint radiopaque shadow of an object or structure superimposed over normal anatomic structures on the opposite side of the patient and found on extraoral images. Ghost images are magnified, somewhat blurred and less radiopaque than the object itself. Itwill always occur on the contralateral side and slightly superior to the object of origin. Synonym: ghost shadow. Appendix 11 229Gray (Gy): this unit quantifies the energy absorbed by a given material. The SI unit is called the gray. One gray is equivalent to 100 rad.Ground glass appearance: a very fine bone trabecular pattern resulting in a diffuse radi-opacity that visually resembles ground glass material; it often is associated with the late stage of fibrous dysplasia. (See Fig. X3.)Hair‐on‐end appearance: fine, uniformly arranged spicules of bone starting from the inner table of the cranial vault and extending beyond the outer surface up to a couple of cen-timeters. The outer cortical plate is absent.Half value layer (HVL): the thickness of mate-rial required to reduce the intensity of an x‐ray beam by 50%. It is used to measure the pene-trating ability or quality of an x‐ray beam.Hamular process: a short, hook‐like process extending inferiorly from the medial pterygoid plate. It may be observed on intraoral images of the maxillary tuberosity as a thin, radiopaque projection angled down and posteriorly from the medial pterygoid plate. The gap between the hamular process and the maxillary tuberos-ity is referred to as the hamular notch.Hertz (Hz): the SI unit of electrical frequency. It is equal to one cycle per second. In the United States, household electricity has a frequency of 60 cycles per second or 60 Hz, while in European countries the electrical frequency is 50 Hz.HIPAA (Health Information Portability and Accountability Act): enacted by the US Congress in 1996 to address the use and disclosure of individuals’ personal health information and to protect health insurance coverage for workers and families when they change or lose jobs.Hittorf–Crookes tube: see Crookes–Hittorf tube.Honeycomb appearance: a trabecular pattern having multiple, uniform, typically 2–5 mm oval or round radiolucent compartments in bone. Synonym: polycystic (Fig. X5).Horizontal bone loss: the horizontal destruc-tion of the crestal alveolar bone adjacent to the root surface of two or more teeth.Hydroxyapatite: the main mineral of which tooth enamel and dentin are composed. Synonym: hydroxylapatite.Hypercementosis: the deposition of excess cementum along a root surface; it often produces a bulbous radiographic appearance of the root.Hypocalcified enamel: the correct total amount of enamel but the enamel is undercalcified.Hypoplastic enamel: enamel that has a normal image density, but its thickness has been reduced.Iatrogenic: something that was inadvertently caused by a medical or dental procedure.Indirect digital imaging: the conversion of a latent image into a visible image. Initially a PSP plate directly captures and stores an x‐ray image as a latent image. This latent image is then indirectly converted into a digital image with the use of a special laser scanner. This dif-fers from a solid‐state receptor, which directly sends the image to a computer without the need of a scanner.Image enhancement: the process within a soft-ware program whereby the appearance of a digital image is altered. This is typically modi-fied with the brightness, contrast, filtering and colorization controls.Impaction: a tooth that is physically obstructed and unable to fully erupt into the dental arch.Impaction, bony: an impacted tooth that is obstructed by both bone and soft tissue.Impaction, dental: an impacted tooth that is obstructed by a barrier such as a neighboring tooth.Incipient caries: a caries less than halfway through the enamel; from the meaning of incip-ient being something that is in an early stage of development. 230 Appendix 11Intensifying screen: a screen composed of rare earth materials that multiply the effect of incoming x‐ray photons and thereby reduce the radiation exposure to the patient. The primary disadvantage of using an intensifying screen is that it reduces the overall resolution of the final radiographic image. Extraoral x‐ray film is sandwiched between two intensifying screens that cover the front and back of the film within a light‐tight cassette.Invagination of a crown: an inward fold or cleavage of a crown.Inverse square law: this law states that the inten-sity of radiation at a given point is inversely proportional to the mathematical square of the distance from the source of radiation. Simply stated, this means that if you double the distance of the source of radiation to the receptor, only one‐quarter of the radiation will reach the receptor. With increasing distance the x‐ray beam diverges covering a much larger field. To acquire the same amount of exposure at double the distance, the exposure time would need to be quadrupled.Ionizing radiation: any type of electromag-netic radiation that has sufficient energy to knock an electron out of its atomic orbit. The process of producing an ion by removing an electron is referred to as ionization. Although it is not sharply demarcated, ionizing forms of radiation include shorter wavelength ultravio-let radiation, x radiation and gamma radiation.Isometry: the mathematical rule of isometry states that two triangles are equal when they share a common side. As it applies to the bisect-ing angle intraoral technique, the bisector is the common side.Kerma, air (kinetic energy released per unit mass): the sum of the initial kinetic energies of all the charged particles liberated by indirectly ioniz-ing radiation per unit mass of a specified material.Kilovolt (kV): 1 kV is 1000 V; 60–80 kV is the standard range for intraoral exposures. Kilovoltage represents the potential difference between the cathode and anode in the x‐ray tube. The “p” in kVp indicates the maximum or peak voltage applied across an x‐ray tube.Kinetic energy: the energy of a mass in motion. In an x‐ray tube, electrons accelerate from the cathode to the anode when a high voltage is applied. A very small percentage of that kinetic energy is converted into x‐ray photons.Lace‐like appearance: a bone pattern that resembles fine threads. Synonyms: net, regular network.Lagniappe: means something extra.Lamina dura: the radiopaque line forming the outline of the tooth socket in the alveolar bone.Latent image: a recorded image produced after exposure to radiation that cannot be visualized until it is digitally or chemically processed. APSP plate stores a latent image until it is scanned. A dental x‐ray film requires chemical processing.Latent period: the period of time between expo-sure to radiation and the onset of symptoms.Lateral cephalograph: a head profile projec-tion that reveals osseous structures and soft tissue outline of the face. It is typically used in orthodontics for assessing facial growth and development. Alternatively, a lateral skull image does not use a cephalostat nor does it show the soft tissue outline in the image.Law of Bergonie and Tribondeau: a funda-mental law of radiation biology formulated in 1906 by Jean Bergonie, a French radiologist, and Louis Tribondeau, a French physician. The law states that the faster a cell replicates, the more sensitive it will be to radiation, and the more specialized a cell type is, the less sensitive it will be to the effects of radiation. Only two human cell types are currently known to contradict this law. These are the lymphocytes and the oocytes. Both of these cell types are specialized and they are very sensitive to radiation.Line pairs per millimeter (lp/mm): a physical line plus the space adjacent to it is called a line pair. The number of line pairs distinguishable Appendix 11 231within a space of 1 mm is used as a measure-ment of x‐ray image resolution. The higher the number of line pairs per millimeter visible, the greater is the resolution of the image. High res-olution is useful for the detection of caries, a hairline tooth or bone fractures, etc.Lingual foramen: is a tiny opening located on the lingual aspect of midline of the mandible. The lingual artery passes through it. The genial tubercles are frequently seen surrounding it on anterior periapical images.Long PID: a PID (position indicating device) is considered long when the distance from the source of radiation (i.e. focal spot) to the posi-tion of the intraoral receptor is 30 cm or greater; a long PID is required when performing the paralleling technique. Synonym: long cone.Lymphocyte: a specialized white blood cell in the immune system.Mach band effect: an optical illusion that exaggerates the contrast along the borders of objects with differing densities. This can occur along the border of dentin and enamel. An illusionary radiolucent line may be produced which may lead to an erroneous diagnosis of a fracture or caries where none exist.Magnetic resonance imaging (MRI): MRI was invented by Paul Lauterbur together with Sir Peter Mansfield who developed the mathemati-cal technique for reconstructing images in 1971. MRI is non‐invasive and uses non‐ionizing radi-ation, unlike ionizing radiation which is typi-cally used for conventional advanced dental imaging techniques such as CBCT. MRI is best for imaging the soft tissues. In dentistry, its usefulness is limited to soft tissue pathology, the study of the cartilaginous disk of the temporo-mandibular joint and for cosmetic oral and max-illofacial surgery. Disadvantages for dentistry are the high cost of the imaging procedure, long scan times and imaging artifacts from metallic restorations (e.g. amalgams, gold crowns). In addition, any ferromagnetic objects such as aneurysm clips may undergo movement as a result of the strong magnetic field and can result in unexpected injury to a patient. For this proce-dure, the patient is positioned in a large mag-net. The magnetic field generated temporarily results in the realignment and orientation of the protons, particularly hydrogen, which com-prises approximately 70% of the patient’s body. A radio wave signal is aimed at the patient and it is absorbed by some of the hydrogen nuclei. The radio signal is then turned off, the absorbed energy is released from the nuclei and it is detected as a signal by a coil in the scanner. A computer program then constructs the soft tissue images.Malocclusion: see Occlusion.Maximum occupational dose: government reg-ulates the maximum amount of occupational radiation exposure that a worker can receive in a designated period of time. A radiation dosimeter will record the wearer’s total exposure to radia-tion. Occupational workers are permitted to receive up to 5 centisieverts (cSv) in any one year.Maximum permissible dose (MPD): as defined by the International Commission on Radiation Protection (ICRP), MPD is the permissible dose an individual can either accumulate over a long period of time or receive from a single exposure that carries a negligible probability of severe somatic or germ cell injuries.Mid‐sagittal: an imaginary line that antero-posteriorly divides the body along the midline. Synonym: mid‐sagittal plane.Milliampere (mA): 1 mA is one one‐thousandth of an ampere.Milliampere second (mAs): refers to the quan-tity of radiation produced. It is calculated by the milliampere setting and the selected expo-sure time. It affects image density.Moth‐eaten appearance: a poorly defined radiolucent area of bone composed of coalesc-ing, multiple, irregular‐shaped radiolucencies ranging in size from a few millimeters to several centimeters. These radiolucencies show 232 Appendix 11some opacification, indicating only a partial loss of trabeculae within them.Mulberry molar: describes a hypoplasia of enamel of one or more permanent maxillary or mandibular first molars. There is a characteris-tic constriction of the cusps and the occlusal surface that gives a crown a “pinched” appear-ance. The mulberry molar appears normal onx‐ray images, except that it often has short roots. There is no racial or sexual predilection. Synonyms: Moon’s molars and Fournier molars.Multilocular appearance: an irregular pattern of multiple, non‐uniform radiolucent compartments on bone. Synonym: polycystic. (See Fig. X1.)Multiplanar reconstruction (MPR): the raw data accumulated from a CBCT scan that is con-verted by a software program into sagittal, cor-onal and axial planar images.Nanometer (nm): a unit of spatial measure-ment that is one billionth of a meter.Nasal septum: the dividing wall composed of bone and cartilage that runs down the center of the nasal fossa. (See Fig. U4.)Nasion: the middle point of the junction of the frontal and two nasal bones. Superficially, it is the midpoint between the patient’s eyes. It is a commonly used cephalometric landmark for orthodontic evaluation.Nasolacrimal canal: contains the nasolacrimal duct and opens beneath the inferior nasal con-cha. On periapical images, it may occasionally be observed as a small ovoid radiolucency located superior to the apex of the cuspid.Negative vertical angulation: the direction of the PID when it originates from below the occlusal plane and it is directed upwards.Nutrient canals: thin channels within bone carrying nerve and blood vessels. They will appear on x‐ray images as thin radiolucent lines often in the mandibular anterior region. Synonym: neurovascular canals.Occlusal plane: an imaginary plane formed by the occlusal surfaces of the maxillary and man-dibular teeth when the jaws are closed together.Occlusal image: a topographic projection of either the maxilla or mandible utilizing either the bisecting angle or cross‐sectional technique; useful for localization of impactions, fractures, root tips, and foreign bodies.Occlusion, class I: the mesiobuccal cusp of the maxillary first molar aligns with the buccal groove of the mandibular first molar.Occlusion, class II: the buccal groove of the mandibular first molar is distally positioned when in occlusion with the mesio‐buccal cusp of the maxillary first molar.Occlusion, class III: the buccal groove of the mandibular first molar is mesially positioned when in occlusion with the mesio‐buccal cusp of the maxillary first molar.Onion peel appearance thin layers of calcified bone tissue located adjacent and parallel to the outer surface of the cortical plate. Synonyms: layered, laminated.Onlay restoration: an indirect restoration that is fabricated extraorally. It is fabricated for a tooth that does not require a full crown and when a conventional restoration may be struc-turally unsound. An onlay typically incorporates a tooth cusp.Oocyte: an immature female reproductive cell prior to fertilization.Osteonecrosis: bone degeneration as a result of decreased blood flow. A deficiency of blood causes the bone to degenerate faster than the body can regenerate new bone. Synonyms: avascular necrosis, aseptic necrosis, ischemic necrosis.Osteoradionecrosis of the jaws: the adminis-tration of high therapeutic doses of ionizing radiation for oral cancer (over 50 Gy) may result in irreversible hypovascular bone. Reduction in Appendix 11 233bone vascularity causes it to become more susceptible to infection and traumatic injury. The ultimate result is bone degenerating faster than the body can regenerate new bone. The mandible is more often affected than the maxilla. Osteoradionecrosis appears similar to osteomyelitis on x‐ray images.Overexposure, image: an x‐ray image that overall appears too dark. Contributing factors may include any or all of the following: high kilovoltage, high milliamperage or long expo-sure time setting. X‐ray film can be excessively dark from exposure to external light sources prior to processing.Palatoglossal air space: the gap between the dorsal surface of the tongue and the palate. It may appear as a crescent‐shaped radiolucent band across a panoramic image.Panoramic image: an unobstructed two‐dimensional extraoral view of the entire mouth in a single image. It captures all of the teeth, maxilla, mandible and surrounding structures. Synonym: pantomogram.Panorex®: the commercial name for an early model of a panoramic unit (circa 1967) sold by the S. S. White Division of the Pennwalt Corp., Philadelphia, PA.Paralleling technique: an intraoral tech-nique where the long axis of the tooth and the receptor are positioned parallel to one another and the x‐ray beam is aimed perpendicular to both of them. This maximizes the accuracy of the projected image and thus minimizes distortion.Paresthesia: a transient or chronic sensation known as a pins and needles tingling of a person’s skin. In dentistry, it typically arises from damage to the inferior alveolar nerve.Particulate radiation: this is composed of atomic or subatomic particles having both mass and energy. Particulate radiation includes alpha particles, beta particles and neutrons.Penumbra: the blurriness or area of unsharp-ness found along the edge of an x‐ray image. Multiple factors can affect image unsharpness, including focal spot size, motion, tube–receptor distance and tube–object distance.Periapical: refers to the region around the root tip (apex) of a tooth.Periapical image: an intraoral image that shows one or more teeth in their entirety. In edentulous regions, a periapical image is useful for visualizing root tips, impactions and foreign bodies.Periapical lesion: active or inactive pathology located at the apex of a tooth. It may be either a radiopaque or a radiolucent lesion.Periapical scar: an unresolved periapical radi-olucency associated with an endodontically treated tooth. It may be a periapical lesion that healed with fibrous tissue in lieu of mature bone.Pericoronal: refers to the region around the crown of a tooth.Pericoronitis: refers to the inflammation of thesoft tissues surrounding the crown of a par-tially erupted tooth.Periodontal ligament space (PDL space): the radiolucent gap (i.e. space) between the lamina dura and the root surface on an x‐ray image. The PDL space may appear to be absent simply because the operator positioned the PID at an oblique angle to the buccal surface of the tooth. It is important to be aware that actual widening or loss of the PDL space may be an indicator of pathology.Personal protection equipment (PPE): refers to the universal infection control guidelines as mandated in the United States by the Occupational Safety and Health Administration (OSHA). All dental personnel directly involved with patient care must wear protective clothing. Disposable or non‐disposable gowns must be long‐sleeved, at least three‐quarter in length and have a closed collar. In addition, disposable protective gloves 234 Appendix 11should always be worn by the operator during receptor and tubehead placement to minimize risks to both the operator and the patient. For x‐ray imaging procedures, aerosols are not gener-ated but exposure to bodily fluids is still unavoidable. Consequently, operators may wish to wear protective eyewear and a mask or face‐shield. Image receptors must be covered with dis-posable plastic non‐permeable wraps. Computer components (i.e. keyboard and mouse) and x‐ray equipment (i.e. tubehead and control panel) should be protected with surface barriers that are changed after each patient. If barriers are not used, equipment that has come into contact with the operator’s gloved hands should be cleaned and then disinfected after each patient use.Phleboliths: typically are small, round calcifica-tions located within venous structures, and are often associated with hemangiomas. (See Fig. X4.)Photon: a packet of energy that has no mass. It is ascribed to electromagnetic radiation, which includes radio waves, visible light, x rays, gamma rays, etc.Photostimulable phosphor plate (PSP plate): is a polyester base material coated with a halide emulsion. It stores the energy from incoming x‐ray photons as a latent image. The latent image is then converted into visual image by a laser scanner. The PSP plate can be reused after erasure of the image, disinfection and repack-aging. (See Indirect digital imaging.)PID (position indicating device): the open‐end extension off the x‐ray tubehead through which x rays are directed. The shape of the PID may either be round or rectangular. Synonym: BID (beam indicating device).Pixel: the smallest, basic component of a digi-tal image that can be processed.Pneumatization: the development of air cells (aka cavities) within a bone.Positive vertical angulation: the direction of the PID when it originates from above the occlusal plane and it is directed downwards.Primary radiation: the beam of radiation that directly exits the PID of an x‐ray tubehead.Processor, film: a device that is used to turn a latent x‐ray image on a piece of x‐ray film into a visible image with the use of chemical solu-tions. An automatic film processor is a machine that mechanically moves each film(s) through multiple chemical solutions to produce a visible image. The processed film is called a radio-graph. Manual film processing involves an opera-tor manually hand dipping the x‐ray film(s) in different chemical solutions to produce a final radiograph.Proprietor: the owner of a business.Punched out appearance: one or more well‐defined round or oval‐shaped radiolucencies ranging in diameter from 1 cm to several cen-timeters. These radiolucencies show no opaci-fication, such as trabeculae, within them.Quality assurance: the regular monitoring of x‐ray equipment to ensure that proper stand-ards of quality are being met. The objective is to achieve optimum diagnostic images and the elimination of unnecessary radiation exposure to patients, occupational workers and the general public.Quality of the x‐ray beam: refers to the mean energy or penetrating ability of the x‐ray pho-tons. It is affected by the kilovoltage setting of the x‐ray unit. It is characterized by its half value layer.Quantity of the x‐ray beam: refers to the total number of x‐ray photons generated during an exposure. It is affected by the milliamperage, time and kilovoltage settings of the x‐ray unit.Radiation, natural background: see Background radiation.Radiation absorbed dose (rad): the traditional unit for quantifying the energy absorbed by a given material. The SI unit for rad is called the gray (Gy). The conversion is 1 Gy equals 100 rad.Radiation biology: the study of the effects of ionizing radiation on living things. Appendix 11 235Radiation caries: an indirect effect of thera-peutic irradiation. Radiotherapy for the treat-ment of oral cancer may result in the loss of function of the salivary glands. Reduced sali-vary flow places the individual in a higher risk category for dental caries. Radiotherapy may incapacitate the individual and limit their ability to maintain their oral hygiene adequately.Radioactivity: the property of some unstable elements to spontaneously emit radiation. This may include alpha particles, beta particles and gamma rays.Radiograph: a term originally used to apply to a visible image on a processed piece of x‐ray film. The term radiograph is still used to describe digital x‐ray images. Synonym: x‐ray image.Radiolucent: describes the penetrability of x‐ray photons through an object to produce the darker colored regions on a radiograph.Radiopaque: describes the impenetrability of x‐ray photons through an object to produce the lighter colored regions on a radiograph.Rectangular PID: a rectangular‐shaped x‐ray beam recommended by the National Council on Radiation Protection and Measurements for reducing the volumetric area of exposure to the patient compared to a conventional round PID. Synonym: rectangular collimator.Rectification: the conversion of alternating current to direct current. Self‐rectification is the property of an x‐ray tube to restrict the flow of electricity to only one direction (i.e. from the cathode to the anode).Residual cyst: a chronic cyst resulting from the incomplete removal of the original cyst.Resolution, image: a measure of how closely two objects can be placed side by side and still be distinguishable as separate objects. Resolution of x‐ray images is defined by the number of line pairs per millimeter that are discernible.Resolution, spatial: refers to the number of pixels used in digital image construction.Resorption, root: (1) Smooth root resorption: the root will appear shortened or blunted, but its surface is relatively smooth and it is surrounded by a distinct periodontal ligament space. (2) Rough root resorption: the root will appear with an irregular surface, with the periodontal liga-ment space either widened or non‐existent. (3) Internal resorption: destruction of the dentin from the pulp chamber outwards creates a round or oval radiolucent area associated with the pulp. If it progresses far enough, it will reach the external surface of the root.Roentgen (R): a measure of ionization pro-duced in air by x rays or gamma rays. It was named after the discoverer of x rays, Professor Wilhelm Röntgen. Roentgen units have been replaced with the SI unit, coulombs per kilogram. One roentgen equals 258 μC/kg.Roentgen equivalent man (rem): the tradi-tional unit used to compare the biologic effects of different types of radiation on a tissue or organ. The SI unit for rem is called the sievert (Sv). The conversion is 1 Sv equals 100 rem.Ruhmkorff coil: a type of transformer used to produce high voltages from low voltage direct current. It was originally used in conjunction with a Crookes–Hittorf tube to generate x rays.Sagittal plane: the vertical plane that runs parallel to the median.Scalloped appearance: a well‐defined, undu-lating border with the indentations being of similar size.Scanner, PSP plate: PSP plates must pass through a specialized laser scanner that reads and digitizes the acquired images. The processed images can then be viewed on a computer monitor.Scatter radiation: the deviation of x‐ray pho-tons from their original path upon interaction with matter. 236 Appendix 11Sclerosis of bone: an ill‐defined radiopaque area characterized by: (i) a reduction in the size of the trabecular spaces; (ii) an increase in the number of trabeculae and an increase in the opacity of the involved bone; and (iii) a varia-ble, size ranging from millimeters to several centimeters. Synonyms: sclerosing osteitis, condensing osteitis, bone sclerosis.Scoliosis: an abnormal curving of the spine.Scout image: a preliminary CBCT image taken prior to the actual scan. Synonym: preview image.Secondary radiation: a weaker form of x radia-tion produced after the incoming x rays interact with matter.Septum, osseous (pl septae): a bony wall that subdivides a larger space.Sharpness: the ability of the imaging receptor to define the edge of an object.Short PID: a PID (position indicating device) is considered short when the distance from the source of radiation (i.e. focal spot) to the place-ment of the intraoral receptor is no more than 20 cm. Synonym: short cone.Sievert (Sv): compares the biologic effects of different types of radiation on a tissue or organ. The SI unit is a sievert and replaces the traditional unit rem. One sievert is equivalent to 100 rem.Sinus lift: a surgical bone augmentation pro-cedure in the maxillary sinus to allow the place-ment of posterior implants when the maxillary alveolar ridge height is insufficient.SLOB rule (same–lingual, opposite–buccal): an intraoral technique used to localize objects from a bucco‐lingual perspective by exposing two images using different angulations. Objects that are on the lingual side will not appear to move, while objects towards the buccal side will shift in an opposite direction from the movement of the PID.Soap bubble appearance: a grape‐like cluster of circular compartments of variable size. Synonyms: multiloculated, polycystic. (See Fig. X1.)Somatic cells: includes all of the tissue cell types in the body with the exception of the two germ cells, the oocytes and spermatocytes.Somatic effects: the deleterious effects of radi-ation observed in the exposed individual only. The radiated individual’s future offspring will not be affected if the germ cells were not affected by the radiation.Sterilize: a mechanism for destroying all living microorganisms.Stochastic effects: refers to the random bio-logic effects of radiation without a requirement to surpass a threshold exposure dose level. The probability of occurrence is proportional to the dose but the severity of the effect is independ-ent of it. A primary stochastic effect is cancer. (See Deterministic effects.)Submerged teeth: deciduous teeth that have undergone a degree of root resorption and have become ankylosed to the bone.Sunburst appearance: description of fine or coarse spicules of bone that radiate perpen-dicularly from the cortical plate. The spicules may be few in number or form a continuous palisade with their length ranging from a few millimeters to a couple of centimeters. Synonyms: starburst, sunray. (See Fig. X7.)Supernumerary tooth: the presence of an extra tooth in excess of the normal complement of teeth. A supernumerary tooth can be well‐formed or misshaped.Taurodont: a tooth with a large body and pulp chamber, very little root formation and an over-all tooth size that is normal.Threshold dose: the minimum exposure dose when a measurable effect will manifest itself.Thyroid collar: additional shielding wrapped around the patient’s neck to protect the thyroid gland from x‐ray exposure.Tomography: a technique for imaging a single plane of a three‐dimensional object by blurring Appendix 11 237out structures both in front and behind the area of interest.Tomogram: a thin sectional x‐ray image of an object that is acquired with a tomographic x‐ray unit.Torus: a self-limiting bony growth typically located in the mandible near the bicuspids above the mylohyoid ridge and/or in the mid-line of the hardplate (PL tori).Transformer: a device used to either increase or decrease voltage. A step‐down transformer reduces the incoming voltage to the cathode in the x‐ray tube. A step‐up transformer increases the voltage between the cathode and the anode of an x‐ray tube.Transposition: the eruption of a tooth in an abnormal position in the dental arch. Any tooth may be affected, but there is a predilection for the permanent maxillary cuspids and bicuspids. Synonyms: translocated teeth, displaced teeth.Trismus: a spasm of the muscles of mastication that restricts mouth opening.Tubehead, intraoral: the metal housing that contains the x‐ray tube, step‐up and step‐down transformers, lead collimator, aluminum filter, insulating oil and seals and has an attached PID. An intraoral tubehead may be mobile, fixed or hand‐held.Tumefaction: the process of becoming swollen.Umbra: the area of the x‐ray image proper. (See Penumbra.)Underexposure, image: an x‐ray image that overall appears too light. Contributing factors may include any or all of the following: low kilovoltage, low millamperage or a short expo-sure time setting.Unilocular: a radiolucency consisting of only one compartment or chamber. Synonym: uni-cystic. (See Fig. X2.)Universal precautions: a set of procedural directives and guidelines published in 1987 by the US Centers for Disease Control and Prevention (CDC) to prevent parenteral, mucous membrane and non‐intact skin exposures of healthcare workers to blood‐borne pathogens. In 1991, the Occupational Safety and Health Administration (OSHA) imposed requirements on employers of healthcare workers, including engineering controls, provision of protective barrier devices, standardized labeling of bio-hazards, mandatory training of employees in universal precautions, management of acci-dental parenteral exposure incidents and avail-ability to employees of immunization against hepatitis B.Vertical bone loss: the destruction of the crestal alveolar bone adjacent to the root sur-face of two or more teeth resulting in an angu-lar surface.View box: consists of an enclosure with a translucent surface through which light is transmitted. It is used to view processed dental x‐ray films (i.e. radiographs). Synonyms: light box, illuminator.Voxel: a three‐dimensional space unlike the two‐dimensional pixel. The term voxel is derived from a combination of volume and element.Worm eaten appearance: description of bone composed of an irregular pattern of multiple radiolucent channels. The size of the channels can range up to several millimeters wide and up to several centimeters in length.Xerostomia: is a dryness of the mouth as a result of a cessation of normal salivary secre-tion. It may be a side effect of medication or associated with systemic disorders, such as Sjogren’s Syndrome. Patients receiving medical radiotherapy to treat oral cancer often experi-ence loss of function of salivary glands.X‐ray source: the tungsten focal spot on the anode where x rays are generated.X‐ray unit: an apparatus that is used to gener-ate x rays. Synonyms: x‐ray machine, x‐ray device, x‐ray equipment. 238Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.Companion website: www.wiley.com/go/hubar/radiologyAbaza N, EI‐Khashab M, Kreutner Jr. A. (1971) Central myxoma of the mandible. Oral Surg, Oral Med and Oral Pathol. 31:465–71.Abrahms AM, Kirby JW, Melrose RJ. (1974) Cementoblastoma. Oral Surg, Oral Med and Oral Pathol. 38:394–403.Adekeye EO. (1980) Ameloblastoma of the jaws: a survey of 109 Nigerian patients. J of Oral Surg. 38:36–41.Adekeye EO, Edwards MB, Goubran GF. (1978) Ameloblastic fibrosarcoma. Oral Surg, Oral Med and Oral Pathol. 46:254–9.Adekeye EO, Edwards MB, Williams HK. (1984) Advanced central myxoma of the jaws in Nigeria. Int J of Oral Surg. 13:177–86.Ai‐Ru L, Zhen L, Jian S. (1982) Calcifying epithelial odontogenic tumors. J of Oral Pathol. 11:399–406.Ajagbel A, Samuel I, Daramola JO. (1978) Giant cell tumor of the maxilla. Oral Surg, Oral Med and Oral Pathol. 46:759–64.Akinosi JS, Olumide F, Ogunbiyi AJ. (1975) Retrosternal parathyroid adenomas manifesting in the form of a giant cell tumor of the mandible. Oral Surg, Oral Med and Oral Pathol. 3:724–33.Alawi F. (2002) Benign fibro‐osseous diseases of the maxillofacial bones. A review and differential diagnosis. Am J Clin Pathol. 118(Suppl):S50–70.Allard RHB, van der Waal I, van der Kwast AM. (1981) Mucosal antral cysts. Oral Surg, Oral Med and Oral Pathol. 51:2–9.Allard RHB, van der Waal I, van der Kwast AM. (1981) Nasopalatine duct cyst. Int J of Oral Surg. 10:447–61.Alsufyani NA, Lam EW. (2011) Cemento‐osseous dysplasia of the jaw bones: key radiographic features. Dentomaxillofac Radiol. 40:141–6.Alsufyani NA, Lam EW. (2011) Osseous (cemento‐osseous) dysplasia of the jaws: clinical and radio-graphic analysis. J Can Dent Assoc. 77:b70.Altini M, Cohen M, (1982) The follicular primordial cyst – odontogenic keratocyst. Int J Oral Surg. 11:175–82.Altini M, Shear M. (1992) The lateral periodontal cyst: an update. J Oral Pathol Med. 21:245–50.American Dental Association. (2012) Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. ADA Council on Scientific Affairs, US Dept of Health and Human Services, Public Health Service, Food and Drug Administration.American Dental Association Council on Scientific Affairs. (2006) The use of dental radiographs: update and recommendations. J Am Dent Assoc. 137:1304–12.Suggested Reading Suggested Reading 239Angelopoulou E, Angelopoulos AP. (1990) Lateral periodontal cyst. Review of the literature and report of a case. J Periodontol. 61(2):126–31.Angiero F, Moltrasio F, Cattoretti G, Valente MG. (2011) Clinical and histopathological profiles of primary or secondary osteosarcoma of the jaws. Anticancer Res. 31(12):4485–9.Anneroth G, Hansen LS. (1982) Variations in kerati-nizing odontogenic cysts and tumors. Oral Surg, Oral Med and Oral Pathol. 53:546.Anneroth G, Isacsson G, Sigurdsson A. (1975) Benign cementoblastoma (true cementoma). Oral Surg, Oral Med and Oral Pathol. 40:141–6.Anneroth G, Johansson B. (1985) Peripheral amelo-blastoma. Int J of Oral Surg. 11:295–9.Ariji Y, Ariji E, Higuchi Y, Kubo S, Nakayama E, Kanda S. (1994) Florid cemento‐osseous dysplasia. Radiographic study with special emphasis on com-puted tomography. Oral Surg, Oral Med and Oral Pathol. 78:391–6.Arlen M, Tollefsen HR, Huvos AG, Marcove, RC. (1970) Chondrosarcoma of the head and neck. Am J of Surg. 120:456–61.Arndt CAS. (2011) Benign Tumors and Tumor‐like Processes of Bone, 19th edn. Saunders‐Elsevier, Philadelphia.Arnott DG. (1978) Cherubism–an initial unilateral presentation. Br J of Oral Surg. 16:38–45.Astacio JN, Mendez JE. (1974) Benign cementoblas-toma (true cementoma). Oral Surg, Oral Med and Oral Pathol. 38:95–9.August M, Magennis P, Dewitt D. (1997) Osteogenic sarcoma of the jaws: factors which influence the prognosis. Int J Oral Maxillofac Surg. 26:198–204.Austinj Jr. LT, Dahlin DC, Royer RQ. (1959) Giant‐cell reparative granuloma and related conditions affecting the jawbones. Oral Surg, Oral Med and Oral Pathol. 12:1285–95.Azzato N. (1957) Primary chondrosarcoma of the mandible. Plastic and Reconstructive Surg. 19:137–42.Baker RD, D’Onofrio ED, Corio RL, Crawford BE, Terry BC. (1979) Squamous‐cell carcinoma arising in a lateral periodontal cyst. Oral Surg, Oral Med and Oral Pathol. 47(6):495–9.Barker BF, Jenson JL, Howell FV. (1974) Focal osteo-porotic bone marrow defects of the jaws. Oral Surg, Oral Med and Oral Pathol. 38:404–13.Barnes R. (1956) Aneurysmal bone cyst. J of Bone and Joint Surg. 38:301–11.Barros RE, Dominguez FV, Cabrini RL. (1969) Myxoma of the jaws. Oral Surg, Oral Med and Oral Pathol. 27:225–37.Basu MK, Matthews JB, Sear AJ, Browne, RM. (1984) Calcifying epithelial odotogenic tumour. J of Oral Pathol. 13:310–9.Bataineh AB, al Qudah M. (1998) Treatment of man-dibular odontogenic keratocysts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 86(1):42–7.Batcheldor GD, Giansanti JS, Hibbard ED, Waldron CA. (1973) Garre’s osteomyelitis of the jaws. J Am Dent Assoc. 87:892–7.Baty JM, Vogt EC. (1935) Bone changes of leukemia in children. Am J of Roentgenol. 34:310–3.Beighton P, Horan F, Hamersma H. (1977) A review of the osteopetroses. Postgraduate Med J. 507–17.Bell WH. (1959) Sclerosing osteomyelitis of the man-dible and maxilla. Oral Surg, Oral Med and Oral Pathol. 12:391–401.Bender IB. (1944) Bone changes in leukemia. Am J of Ortho and Oral Surg. 30:556–63.Bender IB. (2003) Paget’s disease. J Endod. 29:720–3.Bennett JH, Thomas G, Evans AW, Speight PM. (2000) Osteosarcoma of the jaws: a 30‐year retrospective review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 90:323–33.Berger A. (1947) Solitary central giant‐cell tumor of the jawbones. J of Oral Surg. 5:154–66.Berger A, Jaffe HL. (1953) Fibrous (fibro‐osseous) dysplasia of the jawbones. J of Oral Surg. 11:3–17.Bernier JL, Bhaskar SN. (1958) Aneurysmal bone cysts of the mandible. Oral Surg, Oral Med and Oral Pathol. 11:1018–28.Bernstein HF, Lam RC, Pomije FW. (1958) Static bone cavities of the mandible: review of the literature and report of case. J of Oral Surg. 16:46–52.Bernstein ML, Neal DC. (1985) Oral lesion in a patient with calcinosis and arthritis. J of Oral Surg. 14:8–14.Bertelli A, Costa FQ, Miziara J. (1970) Metastatic tumors of the mandible. Oral Surg, Oral Med and Oral Pathol. 30:21–9.Beylouni I, Farge P, Mazoyer JF, Coudert JL. (1998) Florid cemento‐osseous dysplasia: report of a case documented with computed tomography and 3D imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 85(6):707–11.Beziat JL, Marcelino JP, Bascoulergue Y, Vitrey D. (1997) Central vascular malformation of the mandible: a case report. J Oral Maxillofac Surg. 55:415–9.Bhaskar SN. (1968) Oral pathology in the dental office: survey of 2,575 biopsy specimens. J of Am Dent Assoc. 76:761–6.Bhaskar SN. (1977) Synopsis of Oral Pathology. Mosby, St. Louis. 240 Suggested ReadingBhoweer AL, Shirwatkar LG. (1975) Central heman-gioma of mandible. J of Oral Med. 30:111–3.Biorklund A, Elner A, Snorradottir M. (1979) Ameloblastoma of the maxilla: report of three cases. J of Larynol and Otol. 93:1105–13.Black BK, Ackerman LV. (1950) Tumors of the para-thyroid. Cancer. 3:415–31.Bluestone LI. (1953) Malignant melanoma metastatic to the mandible. Oral Surg, Oral Med and Oral Pathol. 6:237–42.Bodner L, Bar‐Ziv J. (1996) Radiographic features of central giant cell granuloma of the jaws in children. Pediatr Radiol. 26:148–51.Boston HC, Dahlin DC, Ivins JC, Cupps RE. (1974) Malignant lymphoma (so‐called reticulum cell sar-coma) of bone. Cancer. 34:1131–7.Bouckaert MM, Roubenheimer EJ, Jacobs FJ. (2000) Calcifying epithelial odontogenic tumor with intracranial extension: report of a case and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 90:656–62.Boyd RC. (1979) Aneurysmal bone cysts of the jaws. Br J of Oral Surg. 16:248–53.Boysen ME, Olving JH, Vatne K, Koppang HS. (1979) Fibro‐osseous lesions of the craniofacial bones. J of Laryngol and Otol. 93:793–7.Brannon RB. (1976) The odontogenic keratocyst. Oral Surg, Oral Med and Oral Pathol. 42:54–71.Brannon RB, Fowler CB. (2001) Benign fibro‐osseous lesions: a review of current concepts. Adv Anat Pathol. 8(3):126–43.Brannon RB, Fowler CB, Carpenter WM, Corio RL. (2002) Cementoblastoma: an innocuous neoplasm? A clinico‐pathologic study of 44 cases and review of the literature with special emphasis on recur-rence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 93:311–20.Bras JM, Donner R, van der Kwast AM, Snow GB, van der Waal I. (1980) Juxtacortical osteogenic sar-coma of the jaws. Oral Surg, Oral Med and Oral Pathol. 50:535–43.Brodsky HR. (1934) Mandibular cavernous heman-gioma. Dental Digest. 40:60–4.Brødum N, Jensen VJ. (1991) Recurrence of kerato-cysts and decompression treatment. A long‐term follow‐up of forty‐four cases. Oral Surg, Oral Med and Oral Pathol. 72(3):265–9.Bruce KW, Royer RQ. (1952) Central myxoma of the maxilla. Oral Surg, Oral Med and Oral Pathol. 5:1277–81.Bruce KW, Royer RQ. (1953) Multiple myeloma occurring in the jaws. Oral Surg, Oral Med and Oral Pathol. 6:729–44.Brustein HC, Mautner RL. (1976) Osteogenesis imperfecta. Oral Surg, Oral Med and Oral Pathol. 42:42–52.Buchner A. (1991) The central (intraosseous) calcify-ing odontogenic cyst: an analysis of 215 cases. J Oral Maxillofac Surg. 49:330–9.Budnick SD. (1976) Compound and complex odonto-mas. Oral Surg, Oral Med and Oral Pathol. 42:511–5.Bunel K, Sindet‐Pedersen S. (1993) Central hemangi-oma of the mandible. Oral Surg, Oral Med and Oral Pathol. 75:565–70.Burland JG. (1962) Cherubism: familial bilateral osse-ous dysplasia of the jaws. Oral Surg, Oral Med and Oral Pathol. 15:43–68.Butt WP, Hollender L, Stener I. (1969). Mandibular erosion in tumours of the major salivary glands. Acta Radiol. 8:235–40.Byrd DL, Kindrick RD, Dunsworth AR. (1973) Myxoma of the maxilla. J of Oral Surg. 31:123–6.Cabrini RL, Barros RE, Albano H. (1970) Cysts of the jaws: a statistical analysis. J of Oral Surg. 28:485–9.Caffey J, Williams JL. (1951) Familial fibrous swelling of the jaws. Radiology. 56:1–13.CaIman HI. (1952) Multiple myleoma. Oral Surg, Oral Med and Oral Pathol. 5:1302–11.Campos PSF, Panella J, Crusoe’Rebello IM, Azevedo RA, Pena N, Cunha T. (2004) Mandibular ramus‐related Stafne’s bone cavity. Dentomaxillofac Radiol. 33:63–6.Canalis RF, Smith GA, Konrad HR. (1976) Myxomas of the head and neck. Arch of Otolaryngol. 102:300–5.Cangiano R, Mooney J, Stratigos GT. (1972) Osteopetrosis. J of Oral Surg. 30:217–22.Cannon ML, Spiegel RE, Cooley RO. (1983) Hereditary fibrous dysplasia of the jaws (cherub-ism): report of a case. J of Dent for Child. July–August:292–5.Caravolas JG, Pierce JM, Andrews JE, Nazif M. (1981) Mesenchymal chondrosarcoma of the mandible. Oral Surg, Oral Med and Oral Pathol. 52:478–4.Carder HM, Hill JJ. (1966) Asymptomatic rhinolith: a brief review of the literature and case report. Laryngoscope. 3: 524–9.Carlson ER, Marx RE. (2006) The ameloblastoma: primary, curative surgical management. J Oral Maxillofac Surg. 64(3):484–94.Caron AS, Hajdu SI, Strong EW. (1971) Osteogenic sarcoma of the facial and cranial bones. Am J of Surg. 122:719–25.Carr RF, Halperin V. (1968) Malignant ameloblasto-mas from 1953–1966. Oral Surg, Oral Med and Oral Pathol. 26:514–22. Suggested Reading 241Carter LC, Carney YL, Perez‐Pudlewski D. (1996) Lateral periodontal cyst. Multifactorial analysis of a previously unreported series. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 81(2):210–6.Carvalho Silva E, Carvalho Silva GC, Vieira TC. (2007) Cherubism: clinicoradiographic features, treatment, and long‐term follow‐up of 8 cases. JOral Maxillofac Surg. 65(3):517–22.Cash CD, Royer RQ. (1961) Metastatic tumors of the jaws. Oral Surg, Oral Med and Oral Pathol. 14:897–905.Cataldo E, Meyer I. (1966) Solitary and multiple plasma cell tumors of the jaws and oral cavity. Oral Surg, Oral Med and Oral Pathol. 22:630–9.Centers for Disease Control and Prevention. (2016) Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA.Chadwick JW, Alsufyani NA, Lam EW. (2011) The clinical and radiographic features of solitary and cemento‐osseous dysplasia‐associated simple bone cysts. Dentomaxillofac Radiol. 40(4):230–5.Chaudhry AP, Hayes PA, Gorlin RJ. (1958) Hyperparathyroidism involving the mandible. J of Oral Surg. 16:247–51.Chaudhry AP, Robinovitch MR, Mitchell DF, Vickers RA. (1961) Chondrogenic tumors of the jaws. Am J of Surg. 102:403–10.Chaudhry AP, Spink JH, Gorlin RJ. (1958) Periapical fibrous dysplasia. J of Oral Surg. 11:483–8.Chaudhry AP, Vickers RA, Gorlin RJ. (1961) Intraoral minor salivary gland tumors. Oral Surg, Oral Med and Oral Pathol. 14:1194–223.Chaudhuri P. (1978) Ameloblastoma. J of Laryngol and Otol. 92:457–65.Chehade A, Daley TD, Wysocki GP, Miller AS. (1994) Peripheral odontogenic keratocyst. Oral Surg, Oral Med and Oral Pathol. 77(5):494–7.Cheng NC, Lai DM, Hsie MH, Liao SL, Chen YB. (2006) Intraosseous hemangiomas of the facial bone. Plast Reconstr Surg. 117(7):2366–72.Cherrick HM, King Jr. OH, Lucatorto FM, Suggs DM. (1974) Benign cementoma. Oral Surg, Oral Med and Oral Pathol. 37:54–63.Chindia ML. (2001) Osteosarcoma of the jaw bones. Oral Oncol. 37(7):545–7.Cho BH, Jung YH, Nah KS. (2007) The prevalence, clinical and radiographic characteristics of cemento‐osseous dysplasia in Korea. Korean J Oral Maxillofac Radiol. 37:185–9.Chow HT. (1998) Odontogenic keratocyst: a clinical experience in Singapore. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 86(5):573–7.Christensen Jr. RE. (1982) Mesenchymal chondrosar-coma jaws. Oral Surg, Oral Med and Oral Pathol. 54:197–206.Christensen Jr. RE, Propper RH. (1982) Intraosseous mandibular cyst with sebaceous differentiation. Oral Surg, Oral Med and Oral Pathol. 53:591–5.Christensen RW. (1956) Complex composite odon-toma involving the maxilla and maxillary sinus. Oral Surg, Oral Med and Oral Pathol. 9:1156–9.Chuong R, Donoff R, Guralnick W. (1982) The odon-togenic keratocyst. J of Oral Surg. 40:797–803.Cicconetti A, Tallarico M, Bartoli A, Ripari A, Maggiani F. (2004) Calcifying epithelial odonto-genic (Pindborg) tumor: a clinical case. Minerva Stomatol. 53:379–87.Ciola B. (1981) Oral radiographic manifestations of a prostatic carcinoma. Oral Surg, Oral Med and Oral Pathol. 52:105–8.Ciola B, Catema DL, Khang PH. (1975) Radiographic manifestations of a chronic apical rarefying osteitis with an unusual fistulous tract. Oral Surg, Oral Med and Oral Pathol. 39:654–7.Ciola B, Yesner R. (1977) Radiographic manifes-tations of a lung carcinoma with metastases to the anterior maxilla. Oral Surg, Oral Med and Oral Pathol. 44:811–5.Clausen F, Poulsen H. (1963) Metastatic carcinoma to the jaws. Acta Path et Micro Scand. 7:361–74.Clemett A, Williams JH. (1963) The familial occur-rence of infantile cortical hyperostosis. Radiology. 80:409–16.Cline RE, Stenger TG. (1977) Histiocytic lymphoma (reticulum‐cell sarcoma). Oral Surg, Oral Med and Oral Pathol. 43:422–35.Cohen J. (1951) Osteopetrosis. J of Bone and Joint Surg. 33A:923–37.Cohen M. (1984) Hemorrhagic (traumatic) cyst of the mandible associated with a retained root apex. Oral Surg, Oral Med and Oral Pathol. 57:26–7.Cohen MA, Mendelsohn DB, Hertzanu Y. (1984) Chondrosarcoma of the maxilla. Int J of Oral Surg. 13:528–31.Cohen S, Becker GL. (1976) Origin, diagnosis and treatment of the dental manifestations of vitamin D resistant rickets. J of Am Dent Assoc. 92:120–9.Conley J, Stout AP, Healey WV. (1967) Clinico‐patho1ogic analysis of eighty‐four patients with an original diagnosis of fibrosarcoma of the head and neck. Am J of Surg. 114:564–9. 242 Suggested ReadingCook HP. (1961) Oral lymphomas. Oral Surg, Oral Med and Oral Pathol. 14:690–703.Corio RL, Crawford BE, Schaberg SJ. (1976) Benign cementoblastoma. Oral Surg, Oral Med and Oral Pathol. 41: 524–30.Cornelius EA, McClendon JL. (1969) Cherubism – hereditary fibrous dysplasia of the jaws. Radiology. 106:136–42.Correll RW, Wescott WB. (1983) Asymptomatic, ill‐defined radiolucent area in the posterior body of the mandible. J of Am Dent Assoc. 107:460–1.Courage GR, North AF, Hansen LS. (1974) Median palatine cysts. Oral Surg, Oral Med and Oral Pathol. 37:745–53.Courtney RM, Kerr DA. (1975) The odontogenic adenomatoid tumor. Oral Surg, Oral Med and Oral Pathol. 39:424–35.Cowan CG. (1980) Traumatic bone cysts of the jaws. Int J of Oral Surg. 9:287–91.Craig RM, Wescott WB, Correl RW. (1984) A well‐defined coronal radiolucent area involving an impacted molar. J of Am Dent Assoc. 109:612–3.Cranin AN, Cranin SL, Silbersher HW. (1970) Paget’s disease. Dental Rad and Photogr. 43:60–4.Craver LF, Copeland MM. (1935) Changes of the bones in the leukemias. Arch of Surg. 30:639–45.Crawford BE, Weathers DW. (1970) Osteoporotic marrow defects of the jaws. J of Oral Surg. 600–5.Cremin B, Goodman H, Spranger J, Beighton P. (1982) Wormian bones in osteogenesis imperfecta and other disorders. Skel Rad. 8:35–8.Curran J, Collins AP. (1973) Benign (true) cemento-blastoma of the mandible. Oral Surg, Oral Med and Oral Pathol. 35:168–72.Curtis ML, Hatfield CG, Pierce JM. (1973) A destructive giant cell lesion of the mandible. J of Surg. 31:705–8.Dabska M, Buraczewski J. (1968) Aneurysmal bone cyst. Cancer. 23:371–89.Dahlgren SE, Lind PO, Lindbom A, Martensson G. (1969) Fibrous dysplasia of the jawbones. Acta Otolaryngol. 68:257–70.Dahlin DC. (1978) Bone Tumors, General Aspects and an Analysis of 6,221 Cases. Thomas, Springfield.Dahlin DC, Besse Jr. B, Pugh DG, Ghormley RK. (1955) Aneurysmal bone cyst. Radiology. 64:56–65.Dahlin DC, Henderson ED. (1962) Mesenchymal chondrosarcoma. Cancer. 15:410–7.Dalati T, Zhou H. (2008) Gorlin syndrome with ameloblastoma: a case report and review of litera-ture. Cancer Invest. 26(10):975–6.Daley TD, Wysocki GP, Pringle GA. (1994) Relative incidence of odontogenic tumors and oral and jaw cysts in a Canadian population. Oral Surg, Oral Med and Oral Pathol. 77:276–80.Dammer R, Niederdellmann H, Dammer P, Nuebler‐Moritz M. (1997) Conservative or radical treatment of keratocysts: a retrospective review. Br J Oral Maxillofac Surg. 35(1):46–8.Darroszewaka A, Ralston SH. (2005) Genetics of Paget’s disease of bone. Clin Sci. 109:257–63.Davis RB, Baker RD, Alling CC. (1978) Odontogenic myxoma. J of Oral Surg. 36:610–5.Dayan D, Buchner A, Gorsky M, Harel‐Raviv M. (1988) The peripheral odontogenic keratocyst. Int J Oral Maxillofac Surg. 17(2):81–3.de Andrade M, Silva AP, de Moraes Ramos‐Perez FM, Silva‐Sousa YT, da Cruz Perez DE. (2012) Lateral periodontal cyst: report of case and review of the literature. Oral Maxillofac Surg. 16:83–7.de Lange J, van den Akker HP. (2005) Clinical and radiologic features of central giant cell lesions of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 99:464–70.DeBoom GW, Jenson JL, Siegel W, Bloom C. (1985) Metastatic carcinomas of the mandible. Oral Surg, Oral Med and Oral Pathol. 60:512–6.Deighan WJ, Ashley WW, Lazansky JP. (1956) Complex composite odontoma. Oral Surg, Oral Med and Oral Pathol. 9:263–8.Demicco EG, Deshpande V, Nielsen GP, Kattapuram SV, Rosenberg AE. (2010) Well‐differentiated osteo-sarcoma of the jaw bones: a clinicopathologic study of 15 cases. Am J Surg Pathol. 34(11):1647–55.DeTomasi D, Hann JR. (1985) Traumatic bone cyst: report of case. J of Am Dent Assoc. 111:56–7.Dick HM, Simpson WJ. (1972) Dental changes in osteopetrosis. Oral Surg, Oral Med and Oral Pathol. 34:408–16.Dickson DD, Camp JD, Ghormley RK. (1945) Osteitis deformans: Paget’s disease of the bone. Radiology. 44:449–70.DiFiore P, Bowen S. (2010) Cemento‐osseous dys-plasia in African‐American men: a report of two clinical cases. J Tenn Dent Assoc. 90:26–9.Drage NA, Whaites EJ, Hussain K. (2003) Haemangioma of the body of the mandible: a case report. Br J Oral Maxillofac Surg. 41:112–4.Duffy JH, Driscoll EJ. (1958) Oral manifestations of leukemia. Oral Surg, Oral Med and Oral Pathol. 11:484–90.Duinkerke ASH, Van de Poel ACM, Doesburg WH. (1975) Variations in the interpretation of periapical radiolucencies. Oral Surg, Oral Med and Oral Pathol. 40:414–21. Suggested Reading 243Dyson DP. (1970) Osteomyelitis of the jaws in Albers‐Schonberg disease. Br J of Oral Surg. 7:178–87.Eisenbud L, Attie J, Garlick J, Platt N. (1987) Aneurysmal bone cyst of the mandible. Oral Surg, Oral Med and Oral Pathol. 64:202–6.el‐Hajj G, Anneroth G. (1996) Odontogenic kerato-cysts. A retrospective clinical and histologic study. Int J Oral Maxillofac Surg. 25(2):124–8.Eliasson S, Isacsson G, Kondell PA. (1989) Lateral periodontal cysts. Clinical, radiographical and histopathological findings. Int J Oral Maxillofac Surg. 18(4):191–3.Epstein JB, Voss NJS, Stevenson‐Moore P. (1984) Maxillofacial manifestations of multiple myeloma. Oral Surg, Oral Med and Oral Pathol. 57:267–71.Eugenidis N, Olah AJ, Haas HG. (1972) Hyper-parathyroidism. Radiology. 105:265–75.Eversole LR, Leider AS, Nelson K. (1985) Ossifying fibroma: a clinico‐pathologic study of sixty‐four cases. Oral Surg, Oral Med and Oral Pathol. 60:505–11.Eversole LR, Leider AS, Strub D. (1984) Radiographic characteristics of cystogenic ameloblastoma. Oral Surg, Oral Med and Oral Pathol. 57:572–7.Eversole LR, Rovin S. (1972) Differential radiographic diagnosis of lesions of the jawbones. Diag Rad. 105:277–84.Eversole LR, Sabes WR, Dauchess VG. (1973) Benign cementoblastoma. Oral Surg, Oral Med and Oral Pathol. 36:824–30.Eversole LR, Sabes WR, Rovin S. (1975) Aggressive growth and neoplastic potential of odontogenic cysts: with special reference to central epidermoid and mucoepidermoid carcinomas. Cancer. 35(1): 270–82.Eversole LR, Stone CE, Strub D. (1984) Focal scleros-ing osteomyelitis – focal periapical osteopetrosis. Oral Surg, Oral Med and Oral Pathol. 58:456–60.Eversole R, Su L, El Mofty S. (2008) Benign fibro‐osseous lesions of the craniofacial complex. Areview. Head Neck Pathol. 2:177–202.Fantasia JE. (1979) Lateral periodontal cyst. An analy-sis of forty‐six cases. Oral Surg, Oral Med and Oral Pathol. 48(3):237–43.Farman AG, Nortje CJ, Grotepass FW, Farnam J, Van Zyl JA. (1977) Myxofibroma of the jaws. Br J of Oral Surg. 15:3–18.Farnam J, Griffen JE, Schow CE, Mader JT, Grant JA. (1984) Recurrent diffuse osteomyelitis involving the mandible. Oral Surg, Oral Med and Oral Pathol. 57:374–8.Feinberg SE, Finkelstein MW, Page HL, Dembo JB. (1984) Recurrent “traumatic” bone cysts of the mandible. Oral Surg, Oral Med and Oral Pathol. 57:418–22.Fernández LR, Luberti RF, Domínguez FV. (2003) Radiographic features of osseous hemangioma in the maxillo‐facial region. Bibliographic review and case report. Med Oral. 8(3):166–77.Finklestein JB. (1970) Osteosarcoma of the jaw bones. Radiol Clin of N Am. 8:425–43.Finley DB, Franklyn P. (1979) Changes in the skull in acute lymphoblastic leukemia of childhood. Clin Radiol. 30:431–3.Fitzgerald GWN, Frenkiel L, Black MJ, Rochon, L, Baxter JD. (1982) Ameloblastoma of the jaws: a 12‐year review of the McGill experience. J of Otolaryngol. 11:23–8.Flax N. (1933) Multiple myeloma. Am J of Roentgenol. 29:479–86.Fordham CC, Williams TF. (1963) Brown tumor and secondary hyperparathyroidism. N Engl J Med. 269:129–31.Formoso Senande MF, Figueiredo R, Berini Aytes L, Gay Escoda C. (2008) Lateral periodontal cysts: a retrospective study of 11 cases. Med Oral Patol Oral Cir Bucal. 13(5):E313–7.Forssell K, Sorvari TE, Oksala E. (1974) An analysis of the recurrence of odontogenic keratocysts. Proc. of Finn Dent Soc. 70:135–40.Frame B, Marel GM. (1981) Paget’s disease: a review of current knowledge. Radiology. 141:21–4.Franklin CD, Craig GT, Smith CJ. (1979) Quantitative analysis of histological parameters in giant cell lesions of the jaws and long bones. Histopathology. 3:511–22.Franklin CD, Pinborg JJ. (1976) The calcifying epithe-lial odontogenic tumor. Oral Surg, Oral Med and Oral Pathol. 42:753–65.Freedman GL, Beigleman MB. (1985) The traumatic bone cyst: a new dimension. Oral Surg, Oral Med and Oral Pathol. 59:616–8.Friedman WH, Schwartz AE. (1974) Brown tumor of the maxilla in secondary hyperparathyroidism. Arch of Otolarynol. 100:157–9.Fries JW. (1957) The roentgen features of fibrous dysplasia of the skull and facial bones. Am J of Roentgenol. 77:71–7.Frommer HH. (2005). Radiology for the Dental Professional, 8th edn. Elsevier‐Mosby, St. Louis.Gardner AF, Apter MB, Axelrod JH. (1963) A study of twenty‐one instances of ameloblastoma: a tumor of odontogenic origin. J of Oral Surg. 21:48–55.Gardner DG. (1980) The central odontogenic fibroma: An attempt at clarification. Oral Surg, Oral Med and Oral Pathol. 50:425–32. 244 Suggested ReadingGardner DG. (1984) The mixed odontogenic tumors. Oral Surg, Oral Med and Oral Pathol. 58:166–8.Gargiulo EA, Ziter WD, Mastrocola R. (1971) Calcifying epithelial odontogenic tumor. J of Oral Surg. 29:862–6.Gee JK, Zambito RF, Argentieri GW, Catania AF, Lumerman H. (1972) Paget’s disease of the man-dible. J of Oral Surg. 30:223–7.George Jr. DI, Gould AR, Behr MM. (1984) Intraneural epithelial islands associated with a periapical cyst. Oral Surg, Oral Med and Oral Pathol. 57:58–61.Ghosh BC, Huvos AG, Gerold FP, Miller TR. (1973) Myxoma of the jawbones. Cancer. 31:237–40.Giansanti JS, Waldron CA. (1970) Odontogenic ade-nomatoid tumor. Oral Surg, Oral Med and Oral Pathol. 30:69–86.Gill PW, Leaper DJ, Staniland JR, De Dombal FT. (1973) Observer variation in clinical diagnosis–a computer‐aided assessment of its magnitude and importance in 552 patients with abdominal pain. Meth Inform Med. 12:108–13.Gingrass RP, Hinz LE. (1961) Fibrosarcoma of the mandible. J of Oral Surg. 19:242–4.Glasscock ME, Hunt WE. (1974) Giant cell tumor of the sphenoid and temporal bones. Laryngol. 84:1181–7.Goldberg H, Schoffield IDF, Popowich LD, Wakeham D. (1981) Cystic complex composite odontoma. Oral Surg, Oral Med and Oral Pathol. 51:16–20.Goldberg SJ, Friedman JM. (1975) Ameloblastoma: a review of the literature and report of a case. J of Am Dent Assoc. 90:432–8.Golden AL, Foote J, Lally E, Beideman R, Tatoian J. (1981) Dentigerous cyst of the maxillary sinus causing elevation of the orbital floor. Oral Surg, Oral Med and Oral Pathol. 52:133–6.Goldenberg D, Sciubba J, Koch W, Tufano RP. (2004) Malignant odontogenic tumors: a 22‐year experi-ence. Laryngoscope. 114:1770–4.Gomez LSA, Taylor R, Cohen MM, Shklar G. (1966) The jaws in osteopetrosis. J of Oral Surg. 24: 68–74.Goncalves M, Pispico R, Alves Fde A, Lugao CE, Goncalves A. (2005) Clinical, radiographic, biochemical and histological findings of florid cemento‐osseous dysplasia and report of a case. Braz Dent J. 16(3):247–50.Gowgiel JM. (1979) Simple bone cyst of the mandible. Oral Surg, Oral Med and Oral Pathol. 47:319–22Granite EL, Aronoff AK, Gold L. (1982) Central giant‐cell granuloma of the mandible. Oral Surg, Oral Med and Oral Pathol. 53:240–6.Greditzer HG, McLeod RA, Unni KK, Beabout JW. (1946) Bone sarcomas in Paget’s disease. Radiology. 146:327–33.Greer Jr. RO, Johnson M. (1988) Botryoid odon-togenic cyst: clinicopathologic analysis of ten cases with three recurrences. J Oral Maxillofac Surg. 46(7):574–9.Grimes WD. (1979) Radiolucent and radiopaque images of the jaws. Aust Dent J. 24:5–12.Groot RH, van Merkesteyn JP, Bras J. (1996) Diffuse sclerosing osteomyelitis and florid osseous dys-plasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 81(3):333–42.Gruskin SE, Dahlin DC. (1968) Aneurysmal bone cysts of the jaws. J of Oral Surg. 26:523–8.Gruss JS. (1974) Hemangioma of the mandible: a case report. Br J of Oral Surg. 12:24–32.Guadagnolo BA, Zagars GK, Raymond AK, Benjamin RS, Sturgis EM. (2009) Osteosarcoma of the jaw/craniofacial region: outcomes after multimodality treatment. Cancer. 115(14):3262–70.Gundlach KKH, Schulz A. (1977) Odontogenic myx-oma: Clinical concept and morphological studies. J of Oral Surg. 6:343–58.Gurol M, Burkes Jr. EJ, Jacoway J. (1995) Botryoid odontogenic cyst: analysis of 33 cases. J Periodontol. 12:1069–73.Hadi U, Younes A, Ghosseini S, Tawil A. (2001) Median palatine cyst: an unusual presentation ofa rare entity. Br J Oral Maxillofac Surg. 39(4): 278–81.Haidar Z. (1975) Fibrosarcoma of the mandible: a case report. Br J Oral Surg. 13:78–81.Hamlin WB, Lund PK. (1967) Giant cell tumors of the mandible and facial bones. Arch of Otolaryngol. 86:76–83.Hamner JE, Scofield HH, Cornyn J. (1968) Benign fibro‐osseous jaw lesions of periodontal membrane origin. Cancer. 22:861–78.Handlers JP, Abrams AM, Milder J. (1985) Fibrosarcoma of the mandible presenting as a peri-odontal problem. J of Oral Pathol. 14:351–6.Harder F. (1978) Myxomas of the jaws. Int J of Oral Surg. 7:148–55.Harris WH, Dudley HR, Barry RJ. (1962) The natural history of fibrous dysplasia. J of Bone and Joint Surg. 44A:207–33.Hastleton PS, Simpson W, Craig RDP. (1978) Myxoma of the mandible. Oral Surg, Oral Med and Oral Pathol. 46:396–405.Hayward AL, Sparkes JJ. (1982) The Concise English Dictionary. Omega Books, London. Suggested Reading 245Hayward JR, Melarkey DW, Megquier J. (1973) Monostotic fibrous dysplasia of the maxilla. J of Oral Surg. 31:625–7.Heikinheimo K, Happonen RP, Forssell K, Kuusilehto A, Virtanen I. (1989) A botryoid odontogenic cyst with multiple recurrences. Int J Oral Maxillofac Surg. 18(1):10–3.Henderson MS. (1924) Chronic sclerosing osteitis. J of the Am Med Assoc. 82:945–9.Hendler BH, Abaza NA, Quinn P. (1979) Odontogenic myxoma. Oral Surg, Oral Med and Oral Pathol, 47:203–17.Henrickson P, Wallenius K. (1974) The mandible and osteoporosis. J of Oral Rehab. 1:67–73.Henriksson CO, Jellman O. (1964) Complex odon-toma. Oral Surg, Oral Med and Oral Pathol. 18:64–9.Hertzanu Y, Cohen M, Mendelsohn DB. (1985) Nasopalatine cyst. Clin Radiol. 36:153–8.High AS, Main DM, Khoo SP, Pedlar J, Hume WJ. (1996) The polymorphous odontogenic cyst. J Oral Pathol Med. 25(1):25–31.High CL, Frew Jr. AL, Glass RT. (1978) Osteosarcoma of the mandible. Oral Surg, Oral Med and Oral Pathol. 45:678–84.Higuchi Y, Nakamura N, Tashiro H. (1988) Clinicopathologic study of cemento‐osseous dys-plasia producing cysts of the mandible. Report of four cases. Oral Surg, Oral Med and Oral Pathol. 65(3):339–42.Hillerup S, Hjorting‐Hansen E. (1978) Aneurysmal bone cyst – simple bone cyst: two aspects of the same pathologic entity? Int J of Oral Surg. 7:16–22.Hitchin AD, Mason DK. (1958) Four cases of com-pound composite odontomes. Br Dent J. 104: 269–75.Hivanian AG. (1953) Myxoma of the maxilla. Oral Surg, Oral Med and Oral Pathol. 6:927–36.Hoffer O, Vogel G. (1960) Mixed tumor of the salivary glands of the mandible. Oral Surg, Oral Med and Oral Pathol. 13:519–22.Hoggins GS, Allan D. (1971) Paget’s disease of the maxilla. Br J of Oral Surg. 9:122–5.Hong SP, Ellis GL, Hartman KS. (1991) Calcifying odontogenic cyst: a review of ninety‐two cases with reevaluation of their nature as cysts or neoplasms, the nature of ghost cells, and sub-classification. Oral Surg, Oral Med and Oral Pathol. 72:56–64.Houston GD, Fowler CB. (1997) Extraosseous calcify-ing epithelial odontogenic tumor: report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 83:577–83.Huber AR, Nissanka EH, Amaratunge EAPD, Tilakaratne WM. (2007) Clinicopathologic analysis of osteosarcoma of the jaw bones. Oral Dis. 13(1):82–7.Huebner GR, Turlington EG. (1971) So‐called trau-matic (hemorrhagic) bone cysts of the jaws. Oral Surg, Oral Med and Oral Pathol. 31:354–65.Hunsuck EE. (1968) Osteomyelitis of the mandible. J of Oral Surg. 26:529–33.Iannucci JM, Howerton LJ. (2012) Dental Radiography Principles and Techniques, 4th edn. Saunders‐Elsevier, Philadelphia.Ide F, Shimoyama T. (2005) Peripheral odontogenic keratocyst: reportof two cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 99(1):71–8.Ingram FL. (1962) Radiology of tumors of the mandi-ble. Clinic Rad. 13:47–53.Inoue H, Miki H, Oshimo K, et al. (1995) Familial hyperparathyroidism associated with jaw fibroma: case report and literature review. Clinical Endocrinol. 43:225–9.Jacobs MH. (1955) The traumatic bone cyst. Oral Surg, Oral Med and Oral Pathol. 8:90–4.Jacobsen HH, Vraa‐Jensen G. (1949) Fibrous dysplasia of bone. Acta Radiol. 31:1–15.Jacobson HG. (1985) Dense bone – too much bone. Radiological considerations and differential diag-nosis. Skel Radiol. 13:97–113.Jacobsson S. (1984) Diffuse sclerosing osteomyelitis of the mandible. Int J of Oral Surg. 11:363–85.Jacobsson S, Hallen O, Hollender L, Hansson CG, Lindstrom J. (1975) Fibro‐osseous lesion of the mandible mimicking chronic osteomyelitis. Oral Surg, Oral Med and Oral Pathol. 40:433–43.Jaffe HL, Lichtenstein L, Portis RB. (1940) Giant cell tumor of bone. Arch of Pathol. 30:994–1031.Jayne EH, Hays RA, O’Brien FW. (1961) Cysts and tumors of the mandible. Am J of Roentgenol. 2:292–309.Jones AV, Craig GT, Franklin CD. (2006) Range and demographics of odontogenic cysts diagnosed in a UK population over a 30‐year period. J Oral Pathol Med. 35:500–7.Kaffe I, Ardekian L, Taicher S, Littner MM, Buchner A. (1996) Radiologic features of central giant cell granuloma of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 81:720–6.Kaffe I, Naor H, Buchner A. (1997) Clinical and radiological features of odontogenic myxoma. Dentomaxillofac Radiol. 26:299–303.Kangur TT, Dahlin DC, Turlington G. (1975) Myxo-matous tumors of the jaws. J of Oral Surg. 11:523–8. 246 Suggested ReadingKarabouta I, Tsodoulos S, Trigonidis G. (1991) Extensive aneurysmal bone cyst of the mandible: surgical resection and immediate reconstruction. Oral Surg, Oral Med and Oral Pathol. 71:148–50.Karges MA, Eversole LR, Poindexter BJ. (1971) Antrolith: report of case and review of literature. Jof Oral Surg. 29:812–4.Karja J, Rasanen O. (1972) Fibrous dysplasia of the jawbones. Acta Otolaryngol. 74:138–40Karpawich AJ. (1958) Paget’s disease with osteogenic sarcoma of maxilla. Oral Surg, Oral Med and Oral Pathol. 11:827–34.Kaslick RS, Brustein HC. (1962) Clinical evaluation of osteopetrosis. Oral Surg, Oral Med and Oral Pathol. 15:71–81.Kaugars GE. (1986) Botryoid odontogenic cyst. Oral Surg, Oral Med and Oral Pathol. 62(5):555–9.Kawai T, Hiranuma H, Kishino M, Jikko A, Sakuda M. (1999) Cemento‐osseous dysplasia of the jaws in 54 Japanese patients: a radiographic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 87(1):107–14.Kennett S, Pollick H. (1971) Jaw lesions in familial hyperparathyroidism. Oral Surg, Oral Med and Oral Pathol. 31:592–610.Kerley TR, Schow Jr. CE. (1981) Central giant cell granuloma or cherubism. Oral Surg, Oral Med and Oral Pathol. 51:128–30.Khanna S, Gupta S, Srivastava AB, Samant HC, Khanna NN. (1980) Benign fibro‐osseous lesions of the jaw. Ear, Nose and Throat J. 59:51–8.Khosla VM, Korobkin M. (1970) Cherubism. Am J Dis of Children. 120:458–61.Kilgour CS. (1958) Hemangioma of the mandible. BrJ of Plastic Surg. 10:63–9.Kirby JW, Robinson ME. (1973) Osteitis deformans of the maxilla. J of Oral Surg. 31:64–79.Kline ST, Spatz SS, Zubrow HJ, Fader M. (1961) Large cementoma of the mandible. Oral Surg, Oral Med and Oral Pathol. 14:1421–6.Kohn WG, Collins AS, Cleveland JL, et al. (2003) Guidelines for infection control in dental health‐care settings, 2003. MMWR Recomm Rep 52(RR‐17):1–61.Komabayashi T, Zhu Q. (2011) Cemento‐osseous dys-plasia in an elderly Asian male: a case report. J Oral Sci. 53:117–20.Koteshwer K, Pillai KG, Rao S, Nayak RG. (1982) Osteosarcoma of the facial bones. Int J of Oral Surg. 12:106–9.Kragh LV, Dahlin DC, Erich JB. (1958) Osteogenic sarcoma of the jaws and facial bones. Am J of Oral Surg. 96:496–505.Kramer IRH, Pindborg JJ, Shear M. (1992) WHO Histologic Typing of Odontogenic Tumours, 2nd edn. Springer‐Verlag, Geneva.Krolls SO, Schaffer RC, O’Rear JW. (1980) Chondrosarsarcoma and osteosarcoma of the jaws in the same patient. Oral Surg, Oral Med and Oral Pathol. 50:146–50.Kruse‐Losler B, Diallo R, Gaertner C, Mischke KX, Joos U, Kleinheinz J. (2006) Central giant cell gran-uloma of the jaws: a clinical, radiologic and histo-pathologic study of 26 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 101:346–54.Kusukawa J, Irie K, Morimatsu M, Koyanagi S, Kameyama T. (1992) Dentigerous cyst associated with a deciduous tooth. A case report. Oral Surg, Oral Med and Oral Pathol. 73:415–8.Kuttenberger J, Farmand M, Stoss H. (1992) Recurrence of a solitary bone cyst of the mandibu-lar condyle in a bone graft. Oral Surg, Oral Med and Oral Pathol. 74:550–6.Langland OE, Langlais RP, Preece JW. (2002) Principles of Dental Imaging, 2nd edn. Lippincott, Baltimore.Langland OE, Sippy FH, Langlais RP. (1984) Textbook of Dental Radiology. Thomas, Springfield.LeCornu MG, Chuang SK, Kaban LB, August M. (2011) Osteosarcoma of the jaws: factors which influence the prognosis. J Oral and Maxillofacial Surg. 69(9):2368–75.Legunn KM. (1984) Bilateral occurrence of the lateral periodontal cyst: a case report. Periodontal Case Rep. 6(2):56–9.Lemberg K, Hagstrom J, Rihtniemi J, Soikkonen K. (2007) Benign cementoblastoma in a primary lower molar, a rarity. Dentomaxillofac Radiol. 36:364–6.Li TJ, Yu SF. (2003) Clinicopathologic spectrum of the so‐called calcifying odontogenic cysts: a study of 21 intraosseous cases with reconsideration of the terminology and classification. Am J Surg Pathol. 27(3):372–84.Lida S, Fukuda Y, Ueda T, et al. (2006) Calcifying odontogenic cyst: radiologic findings in 11 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 101(3):356–62.Looser KG, Kuehn PG. (1976) Primary tumors of the mandible. Am J Surg. 132:608–14.López‐Arcas JM, Cebrián L, González J, Burgueño M. (2007) Aneurysmal bone cyst of the mandible: case presentation and review of the literature. Med Oral Patol Oral Cir Bucal. 12:401–3.Lynch DP, Madden CR. (1985) The botryoid odon-togenic cyst. Report of a case and review of the literature. J Periodontol. 56(3):163–7. Suggested Reading 247MacDonald‐Jankowski D. (1995) Traumatic bone cysts in the jaws of a Hong Kong Chinese population. Clin Radiol. 50:787–91.MacDonald‐Jankowski DS. (2003) Florid cemento‐osseous dysplasia: a systematic review. Dento-maxillofac Radiol. 32(3):141–9.MacDonald‐Jankowski DS. (2008) Focal cemento‐osseous dysplasia: a systematic review. Dentomaxillofac Radiol. 37(6):350–60.Mahomed F, Altini M, Meer S, Coleman H. (2005) Cemento‐osseous dysplasia with associated simple bone cysts. J Oral Maxillofac Surg. 63(10):1549–54.Manganaro AM, Millett GV. (1996) Periapical cemen-tal dysplasia. Gen Dent. 44:336–9.Manson‐Hing LR. (1980) Panoramic Dental Radiography, 2nd edn. Thomas, Springfield.Manson‐Hing LR. (1990) Fundamentals of Dental Radiography, 3rd edn. Lea and Febiger, Philadelphia.Mardinger O, Givol N, Talmi YP, Taicher S. (2001) Osteosarcoma of the jaw – the Chaim Sheba Medical Center experience. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 91:445–51.Marx RE, Sawatari Y, Fortin M, Broumand V. (2005) Bisphosphonate‐induced exposed bone (oste-onecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg. 63:1567–75.Marx RE, Stern D. (2003) Oral and Maxillofacial Pathology: a Rationale for Diagnosis and Treatment. Quintessence, Carol Stream.Meara JG, Shah S, Li KK, Cunningham MJ. (1998) The odontogenic keratocyst: a 20‐year clinicopatho-logic review. Laryngoscope. 108(2):280–3.Mendenhall WM, Werning JW, Fernandes R, Malyapa RS, Mendenhall NP. (2007) Ameloblastoma. Am J Clin Oncol. 30(6):645–8.Mendes RA, van der Waal I. (2006) An unusual clinico-radiographic presentation of a lateral periodontal cyst–report of two cases. Med Oral Patol Oral Cir Bucal. 11(2):E185–7.Mendez P, Junquera L, Gallego L, Baladrón J. (2007) Botryoid odontogenic cyst: clinical and pathologi-cal analysis in relation to recurrence. Med Oral Patol Oral Cir Bucal. 12(8):594–8.Miles DA. (2008) Color Atlas of Cone Beam Volumetric Imaging for Dental Applications. Quintessence. Chicago.Mohammadi‐Araghi H, Haery C. (1993) Fibro‐osseous lesions of craniofacial bones: the role of imaging. Radiol Clin North Am. 31:121–34.Morgan TA, Burton CC, Qian F. (2005) A retrospective review of treatment of the odontogenic keratocyst. J Oral Maxillofac Surg. 63(5):635–9.Murphey MD, Robbin MR, McRae GA. (1997) The many faces of osteosarcoma. Radiographics. 17: 1205–31.Nagpal A, Suhas S, Ahsan A, Pai KM, Rao NN. (2005) Central haemangioma: variance in radiographic appearance. Dentomaxillofac Radiol. 34:120–5.Nakayama E, Sugiura K, Ishibashi H, Oobu K, Kobayashi I, Yoshiura K. (2005) The clinical and diagnostic imaging findings of osteosarcoma of the jaw. Dentomaxillofac Radiol. 34:182–8.Napier Souza L, Monteiro Lima Júnior S, Garcia Santos Pimenta FJ, Rodrigues Antunes Souza AC, Santiago Gomez R. (2004) Atypical hypercemento-sis versus cementoblastoma. Dentomaxillofac Radiol. 33:267–270.Nase JB, Suzuki JB. (2006) Osteonecrosis of the jaw and oral bisphosphonate treatment. J Am Dent Assoc. 137:1115–9.National Council on Radiation Protection and Measurement. (2003) Dental X‐ray Protection. NCRP Report 145. National Council on Radiation Protection and Measurements, Bethesda, MD.National Council on Radiation Protection and Measurement. (2017) Radiation Protection in Dentistry and Oral and Maxillofacial Imaging. NCRP Report 177. National Council on Radiation Protection and Measurements, Bethesda, MD.Odukoya O. (1995) Odontogenic tumours: an analysis of 289 cases. J Oral Pathol Med. 24:454–7.Ogasawara T, Kitagawa Y, Ogawa T, Yamada T, Yamamoto S, Hayashi K. (1999) Simple bone cyst of the mandibular condyle with severe osteoarthritis: report of a case. J Oral Pathol Med. 28:377–80.Ogunlewe MO, Oluseyi FA, Wasin LA, Akinola LL, Olutayo J. (2006) Osteogenic sarcoma of the jaw bones: a single institutional experience over a 21 year period. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 101:76–81.Oliveira GG, García‐Rozado A, Rey RL. (2008) Intraosseous mandibular hemangioma. A case report and review of the literature. Med Oral Patol Oral Cir Bucal. 13(8):496–8.Orsini G, Fioroni M, Rubini C, Piattelli A. (2000) Hemangioma of the mandible presenting as a peri-apical radiolucency. J Endod. 26(10):621–2.Peltola J, Magnusson B, Happonen RP, Borrman H. (1994) Odontogenic myxoma–a radiographic study of 21 tumours. Br J Oral Maxillofac Surg. 32:298–302.Peñarrocha M, Bonet J, Mínguez JM, Bagán JV, Vera F, Mínguez I. (2006) Cherubism: a clinical, radio-graphic, and histopathologic comparison of 7 cases. J Oral Maxillofac Surg. 64(6):924–30. 248 Suggested ReadingPetrikowski GC, Pharoah MJ, Lee L, Grace MGA. (1995) Radiographic differentiation of osteogenic sarcoma, osteomyelitis and fibrous dysplasia of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 80:744–50.Philipsen HP, Reichart PA. (1998) Unicystic amelo-blastoma: a review of 193 cases from the literature. Oral Oncol. 34(5):317–25.Philipsen HP, Reichart PA. (2000) Calcifying epithe-lial odontogenic tumor: biological profile based on 181 cases from the literature. Oral Oncol. 36:17–26.Pynn BR, Sands TD, Bradley G. (2001) Benign cementoblastoma: a case report. J Can Dent Assoc. 67:260–4.Regezi JA. (2002) Odontogenic cysts, odontogenic tumors, fibroosseous, and giant cell lesions of the jaws. Mod Pathol. 15(3):331–41.Regezi JA, Sciudba J. (1993) Oral Pathology. Clinical‐Pathologic Correlations. Saunders, Philadelphia.Reichart PA, Philipsen HP. (2004) Odontogenic Tumours and Allied Lesions. Quintessence, London.Rizzoli R, Burlet N, Cahall D, et al. (2008) Osteonecrosis of the jaw and bisphosphonate treat-ment for osteoporosis. Bone. 42(5):841–7.Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. (2004) Osteonecrosis of the jaws with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. 62:527–34.Sadoff RS, Rubin MM. (1990) Fibrosarcoma of the man-dible: a case report. J of Am Dent Assoc. 121:247–8.Schafer TE, Singh B, Myers DR. (2001) Cementoblastoma associated with a primary tooth: a rare pediatric lesion. Pediatr Dent. 23:351–3.Schneck DL, Gross PD, Tabor MW. (1993) Odontogenic myxoma: report of two cases with reconstruction consideration. J Oral Maxillofac Surg. 51:935–40.Scholl RJ, Kellett HM, Neumann DP, Lurie AG. (1999) Cysts and cystic lesions of the mandible: clinical and radiologic‐histopathologic review. RadioGraphics. 19(5):1107–24.Scuibba JJ, Fantasia JE, Kahn LB. (2001) Tumours and cysts of the jaws. In: Atlas of Tumour Pathology. Armed Forces Institute of Pathology, Washington, DC: 26–31.Shear M, Pindborg JJ. (1975) Microscopic features of the lateral periodontal cyst. Scand J Dent Res. 83(2):103–10.Shigematsu H, Fujita K, Watanabe K. (1994) Atypical simple bone cyst of the mandible. A case report. Int J Oral Maxillofac Surg. 23:298–9.Shimizu M, Osa N, Okamura K, Yoshiura K. (2006) CT analysis of the Stafne’s bone defects of the man-dible. Dentomaxillofac Radiol. 35:95–102.Sidhu MS, Parkash H, Sidhu SS. (1995) Central giant cell granuloma of the jaws–review of 19 cases. Br J Oral Maxillofac Surg. 33:43–6.Sisman Y, Etoz OA, Mavili E, Sahman H, Ertas Tarım E. (2010) Anterior Stafne bone defect mimicking a residual cyst: a case report. Dentomaxillofac Radiol. 39:124–6.Slootweg PJ. (1992) Cementoblastoma and osteoblas-toma: a comparison of histological features. J Oral Pathol Med. 21:385–9.Slootweg PJ. (2009) Lesions of the jaws. Histopathol. 54(4):401–18.Smith MH, Brooks SL, Eldevik OP, Helman JI. (2007) Anterior mandibular lingual salivary gland defect: a report of a case diagnosed with cone‐beam com-puted tomography and magnetic resonance imag-ing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 103:71–8.Smith S, Patel K, Hoskinson AE. (1998) Periapical cemental dysplasia: a case of misdiagnosis. Br Dent J. 185(3):122–3.So F, Daley TD, Jackson L, Wysocki GP. (2001) Immunohistochemical localization of fibroblast growth factors FGF‐1 and FGF‐2, and receptors FGFR2 and FGFR3 in the epithelium of human odontogenic cysts and tumors. J Oral Pathol Med. 30(7):428–33.Standish SM, Shafer WG. (1958) The lateral perio-dontal cyst. J Periodontol. 29:27–33.Stavropoulos F, Katz J. (2003) Central giant cell gran-ulomas: a systematic review of the radiographic characteristics with the addition of 20 new cases. Dentomaxillofac Radiol. 31:213–21.Su L, Weathers DR, Waldron CA. (1996) Distinguishing features of focal cemento‐osseous dysplasia and cemento‐ossifying fibroma. A histo-pathologic spectrum of 316 cases. Oral Surg, Oral Med and Oral Pathol. 82:205–15.Su L, Weathers DR, Waldron CA. (1997) Distinguishing features of focal cemento‐osseous dysplasias and cemento‐ossifying fibromas: a pathologic spectrum of 316 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 84(3):301–9.Su L, Weathers DR, Waldron CA. (1997) Distinguishing features of focal cemento‐osseous dysplasia and cemento‐ossifying fibromas: a clinical and radio-logic spectrum of 316 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 84(5):540–9. Suggested Reading 249Suljak JP, Bohay RN, Wysocki GP. (1998) Lateral periodontal cyst: a case report and review of the literature. J Can Dent Assoc. 64(1):48–51.Sumer M, Gunduz K, Sumer AP, Gunhan O. (2006) Benign cementoblastoma: a case report. Med Oral Patol Oral Cir Bucal. 11:E483–5.Summerlin DJ, Tomich CE. (1994) Focal cemento‐osseous dysplasia: a clinicopathologic study of 221 cases. Oral Surg, Oral Med and Oral Pathol. 78:611–20.Telfer MR, Jones GM, Pell GM, Eveson JW. (1990) Primary bone cyst of the mandibular condyle. Br J Oral Maxillofac Surg. 28:340–3.Thomas DW, Shepherd JP. (1994) Paget’s disease of bone: current concepts in pathogenesis and treat-ment. J of Oral Pathol and Med. 23(1):12–6.Toida M. (1998) So‐called calcifying odontogenic cyst: review and discussion on the terminology and classification. J Oral Pathol Med. 27:49–52.Tolar J, Teitelbaum SL, Orchard PJ. (2004) Osteopetrosis. N Engl J Med. 351(27):2839–49.Van Rensburg LJ, Nortje CJ, Wood RE. (1994) Advanced imaging in evaluation of a central mandibular hemangioma. Dentomaxillofac Radiol. 23:111–6.Vieira AP, Meneses Jr. JM, Maia RL. (2007) Cementoblastoma related to a primary tooth: a case report. J Oral Pathol Med. 36:117–9.von Wowern N. (2000) Cherubism: a 36‐year long‐term follow‐up of 2 generations in different fami-lies and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 90(6):765–72.von Wowern N. (2001) General and oral aspects of osteoporosis: a review. Clin Oral Invest. 5(2):71–82.Voytek T, Ro J, Edeiken J, Ayala A. (1995) Fibrous dysplasia and cemento‐ossifying fibroma: a histo-logic spectrum. Am J Surg Pathol. 19:775–81.Waldron CA. (1993) Fibro‐osseous lesions of jaws. JOral Maxillofac Surg. 51:828–35.Wang WC, Cheng YS, Chen CH, Lin YJ, Chen YK, Lin LM. (2005) Paget’s disease of bone in a Chinese patient: a case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 99:727–33.Weathers DR, Waldron CA. (1973) Unusual multi-locular cysts of the jaws (botryoid odontogenic cysts). Oral Surg, Oral Med and Oral Pathol. 36(2): 235–41.Weber AL. (1993) Imaging of cysts and odontogenic tumors of the jaw. Definition and classification. Radiol Clin North Am. 31:101–20.Whaites E, Drage N. (2013) Essentials of Dental Radiography and Radiology, 5th edn. Churchill Livingstone‐Elsevier, Edinburgh.Whitaker SB, Waldron CA. (1993) Central giant cell lesions of the jaws. Oral Surg, Oral Med and Oral Pathol. 75:199–208.White S, Pharoah M. (2009) Oral Radiology: Principles and Interpretation, 6th edn. Mosby, St. Louis.Williams HK, Mangham C, Speight PM. (2000) Juvenile ossifying fibroma. An analysis of eight cases and a comparison with other fibro‐osseous lesions. J Oral Pathol Med. 29:13–8.Wong GB. (1992) Large odontogenic myxoma of the mandible treated by sagittal ramus osteotomy and peripheral osteoctomy. J Oral Maxillofac Surg. 50:1221–4.Wuehrman AH, Manson‐Hing LR. (1981) Dental Radiology, 5th edn. Mosby, St. Louis.Wysocki GP, Brannon RB, Gardner DG, Sapp P. (1980) Histogenesis of the lateral periodontal cyst and the gingival cyst of the adult. Oral Surg, Oral Med and Oral Pathol. 50(4):327–34.Yousem DM, Kraut MA, Chalian AA. (2000) Major salivary gland imaging. Radiology. 216(1):19–29.Zlotogorski A, Buchner A, Kaffe I, Schwartz‐Arad D. (2005) Radiological features of central haemangi-oma of the jaws. Dentomaxillofac Radiol. 34:292–6.Zolle JE, Neugebauer JE. (2008) Cone‐beam Volumetric Imaging in Dental, Oral and Maxillofacial Medicine. Quintessence, London. Fundamentals of Oral and Maxillofacial Radiology, First Edition. J. Sean Hubar. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.Companion website: www.wiley.com/go/hubar/radiology251IndexPage numbers in bold refer to Tables and italics refer to Figures.abrasion, 161, 162, 208, 216, 221abscess, periapical, 170, 217absorbed dose, 15, 26, 213, 220, 234ALARA, 22, 25, 27, 219, 221alveolar bone (aka alveolar ridge, alveolar crest), 13, 39, 42, 48, 49, 54, 55, 56, 62, 91, 111, 112, 126, 130, 132, 136, 146, 161, 173, 175, 214, 221, 223, 224, 228–230, 236, 237ameloblastoma, 171, 207, 211, 217amelogenesis imperfecta, 39, 157, 159, 216ampere (amp), 13, 219, 221angstrom, 222angulation, (horizontal and vertical), 222anode, 11–13, 222, 223, 225, 227, 228, 230, 235, 237anodontia, 149, 150, 216, 222,anterior nasal spine (ANS), 125, 126, 214, 222ankylosis, 161, 162, 216antrolith, 171, 217apron, 18, 22, 23, 24, 28, 31, 73, 74, 83, 98, 102, 201,221artifact, 61, 66, 73, 79, 95, 142, 162, 178, 231atom, 4, 5, 18, 19, 222, 224, 227atomic number, 222attrition, 157, 158, 162, 216, 222background radiation, 201, 222, 234barrier cover (aka envelopes, sleeves, pouches), 36, 98, 99, 222, 237beam indicating device (BID, aka PID), 26, 231, 234,236beam size, 24, 61, 62, 224biologic effects, 15, 17, 19, 20, 192, 235, 236bisecting angle technique (BTA), 50, 51, 52, 53, 54, 55bisphosphonates, 184, 223bite‐block, 43, 68–70, 74bitewing image, 55, 56, 57, 62, 64, 223bone loss (see also bisphosphonates, 223):horizontal, 39, 229vertical, 39, 191,bone marrow defect, 172, 217bremsstrahlung radiation, 223buccal object rule (aka SLOB rule), 107–110, 236burnout (cervical), 142, 146, 148, 224calcifying epithelial odontogenic tumor (CEOT), 172, 217, 218calculus, 39, 42, 162, 163, 186, 187, 216cancellous bone, 126, 183caries, dental, 163, 216, 141–148, 216, 223, 225 252 Indexcathode, 11, 12, 222, 223cementoblastoma, 172, 217cementum, 124, 146, 151, 152, 155, 156, 161, 172, 182central ray, 59, 223cephalometric projection (aka cephalograph), 85, 86,223cephalostat, 85, 224cherubism, 172, 173, 210, 217collimation (rectangular and round), 24, 25, 26, 224composite restoration, 166, 188compton scatter, 18, 224condensing osteitis, 173, 217, 218, 236cone (aka beam/position indicating device), 26, 231, 234, 236cone beam computed tomography (CBCT), 86–95, 202, 224concrescence, 151, 216cone‐cut, 61, 62, 224contrast, 225coronoid process, 84, 89 133, 214cortical bone, 126, 132, 214, 225cotton wool, 182, 183, 185, 207, 225coulomb, 225curve of spee, 78, 225cyst:aneurysmal bone, 173, 217botryoid odontogenic, 173, 217calcifying odontogenic, 174, 217dentigerous, 171, 174, 217incisive canal, 174, 217lateral periodontal, 175, 217median palatal, 175, 217nasopalatine, 130, 217periapical, 175, 217residual, 176, 235, 217Stafne bone, 176, 194, 217traumatic bone, 176, 217disinfection, 226dens evaginatus, 216, 225dens invaginatus, 152, 216, 225density, 211, 225denticle (aka pulp stone), 152, 153, 216, 226dentigerous cyst, 174, 217dentin, 124, 125, 214, 216dentinal bridge, 153, 216dentinal dysplasia, 157, 158, 216dentinogenesis imperfecta, 157, 158, 161, 216dento‐alveolar abscess, 170DICOM, 36, 219, 226digital imaging (aka digital radiography), 33–37dilaceration, 153, 216, 226distortion, 73, 226dose:effective, 16, 226absorbed, 15, 213, 220, 234dose rate, 19dosimeter (aka badge), 12, 29, 100, 226dysplasia:dentinal, 39, 157, 158, 216ectodermal, 226fibrous, 126, 173, 177, 178, 182, 217, 218, 223, 229florid osseous, 182, 217periapical osseous, 182, 218electromagnetic radiation, 226electron, 4, 226elongation, error, 63, 189, 222, 227enamel pearl, 153, 154, 216erosion, 163, 180, 216, 227errors, technique, 61–67, 74exostosis, 176, 217, 227extraoral imaging (aka extraoral radiography):CBCT, 86–95, 224occlusal, 58–60panoramic, 68, 69, 70, 71, 72, 73, 74, 75–84external auditory meatus, 69, 84, 85external oblique ridge, 134, 135fibrosarcoma, 177, 217, 218filter, 25, 26, 36, 96fluorescence, 6focal spot, 11, 12, 228fog, image, 32, 228foramen:lingual, 133, 134, 136, 215, 231mental, 84, 90, 136, 138, 215, 222incisive, 129, 130, 214foreign body, 40, 42, 163, 164, 178, 216, 217, 228foreshortening, error, 63, 189fossa:glenoid, 84lateral, 130, 214mental, 139, 140, 215nasal, 78, 84, 125, 126, 127, 128, 131, 132, 185, 214submandibular gland, 140, 215fracture, 164, 189, 216fusion, 151, 154, 216gagging, 203gemination, 154, 155, 216genetic effects of radiation, 228genial tubercles, 133, 134, 136, 214giant cell tumor, 173, 178, 179, 217granuloma, central giant cell, 178–180, 217granuloma, periapical, 179gray (Gy), 15, 213, 229, 234 Index 253half value layer (HVL), 229, 234hemangioma, 171, 179, 217, 234HIPAA (Health Insurance Portability and Accountability Act), 229Hutchinson’s incisor, 155, 216hypercementosis, 155, 216, 229hyperparathyroidism, 180, 217hypodontia (aka anodontia), 149, 150hypoplasia, enamel, 158, 216impaction, 93, 94, 165, 216, 229,inferior alveolar canal (aka mandibular canal), 84, 91, 93, 137, 138inverse square law, 230Kells, C.E., 8, 9, 10kilovolt (kV, kVp), 230lamina dura, 125, 230latent image, 33, 230latent period, 17, 230lateral cephalometric image (aka lateral cephalometric radiograph), 85, 126localization technique (aka SLOB rule), 107–110macrodontia, 149, 151, 216mental ridge, 133–135, 139, 215mesiodens, 108, 149, 150metastatic tumor, 180, 217microdont, 150, 151, 216multiple myeloma, 181, 217mylohyoid ridge (aka oblique ridge):external and internal, 135, 136myxoma, 181, 217occlusal plane, 232occlusal projection, 58, 59, 60odontoma (complex and compound), 159, 160, 171,218odontodysplasia, regional, 160, 161, 216oligodontia, 149, 150, 216ossifying fibroma, 182, 217, 218osteomyelitis, 183, 218osteopetrosis, 183, 218osteoporosis, 184, 217osteosarcoma, 93, 184, 218Paget’s disease, 126, 156, 183, 184, 185, 218panoramic image (aka panoramic radiograph), 68, 69, 70, 71, 72, 73, 74, 75–84paralleling technique (aka long cone technique), 41, 42–50particulate radiation, 4, 221, 222, 233periapical abscess, 152, 170, 175phlebolith, 180, 185position indicating device (PID, aka beam indicating device, BID), 26, 231, 234, 236pregnancy concerns (patient or operator), 31, 101, 201, 227protective apron (aka lead apron), 23, 24, 73, 83, 201pterygoid plate (lateral and medial), 9, 89, 128, 214pulp chamber, 125pulpal obliteration, 161, 162, 216pulp stone (aka denticle), 152, 153, 216, 226quality assurance (QA), 22, 96, 234rad (radiation absorbed dose), 234radiation caries, 145, 235radiation monitoring, 29, 100–101, 226, 234radiation protection, 22–29, 223radiograph (aka digital image):contrast, 13, 225density, 36, 225foreign body, 40, 163, 164, 178, 216, 217, 228resolution, 235patient selection criteria, 30–31, 41, 198, 199radiolucent, 235radiopaque, 235rem, 15, 213, 220, 235rectangular collimation, 20, 23, 24, 25, 51resorption:external, 165, 216internal, 165, 166, 216restoration, dental, 145, 166, 167, 168, 169rhinolith, 185,roentgen (R), 15, 213, 235Röntgen, Wilhelm, 6, 7, 8sagittal plane, 235salivary gland tumor, 186scar, periapical, 186, 217scatter radiation, 18, 22, 87, 95, 235secondary radiation, 236shield, barrier, 27, 102sialolith, 186, 194sievert (Sv), 15, 213, 236sinus, maxillary, 84, 89, 90, 126, 127, 130, 131SLOB Rule (aka buccal object rule, Clark’s rule), 107, 108, 109, 110, 236soap bubble, 170, 171, 173, 178, 180, 207, 209, 211, 236supernumerary tooth, 149, 150, 154, 216, 236target (aka anode), 11, 222taurodont, 156, 216, 236temporomandibular joint (TMJ), 40, 84, 90, 91, 93, 94threshold dose, 19, 236thyroid collar, 23, 83, 236timer, 14 254 Indextomography, 83–95, 236torus (pl: tori), 89, 136, 187, 214, 215, 218, 237transformer, 237transposition, 216, 237traumatic bone cyst, 176, 217trismus, 58, 205, 237tubehead, 11, 12, 103Turner’s tooth, 156, 216underexposed, 36, 65universal precautions, 97–99, 237vertebra, 15, 89, 90vertical angulation, 59, 63, 222wavelength, 3, 4x radiation:absorption, 221bremsstrahlung, 223characteristic, 224dose, 9, 15, 16, 19, 226, 227, 236dosimetry badge (see monitoring badge), 29, 100,226effects, genetic, 228effects, somatic, 236protection, 22, 23–29zygoma (zygomatic arch), 84, 111, 112, 129, 130, 214

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