Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 991
  • Home
  • Print this page
  • Email this page
Cover page of the Journal of Health Sciences

 Table of Contents  
Year : 2015  |  Volume : 8  |  Issue : 2  |  Page : 85-90

Dental radiographic signs

1 Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan, India
2 Department of Prosthodontics, Jaipur Dental College, Jaipur, Rajasthan, India
3 Department of Oral Medicine and Radiology, Rajasthan Dental College, Jaipur, Rajasthan, India

Date of Web Publication17-Jan-2016

Correspondence Address:
Swati Phore
Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2349-5006.174234

Rights and Permissions

Many lesions that occur in the jaw present with a similar radiographical appearance and it is often difficult to differentiate among them. Despite the development of various cross-sectional imaging modalities, the radiograph still remains the first, and the most important investigations. Some diseases have typical radiographical signs and findings that are particular to a specific disease. The aim of this review is to describe collective esoteric knowledge, about various radiographic signs associated with the orofacial region.

Keywords: Balloon like appearance, codman′s triangle, signs, soap bubble appearance

How to cite this article:
Phore S, Panchal RS, Baghla P, Nabi N. Dental radiographic signs. Indian J Health Sci Biomed Res 2015;8:85-90

How to cite this URL:
Phore S, Panchal RS, Baghla P, Nabi N. Dental radiographic signs. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2023 Mar 21];8:85-90. Available from: https://www.ijournalhs.org/text.asp?2015/8/2/85/174234

  Introduction Top

The real importance behind the learning of radiographic signs associated with specific diseases is of relevance to the clinical examination of the head and neck. Knowledge of such signs may quickly solve some difficult diagnostic problems and appropriate treatment instituted. The following list takes you through conditions met by the authors in their clinical practice and in examinations which could, therefore, be considered worth knowing and helpful in academic and clinical excellence.

  Radiographic Signs Top

Balloon like appearance/peripheral egg shell effect

The periphery of the expanded cortex is more opaque than the region inside the expanded border. The cortical bone is not thicker on the cortex than over the rest of the lesion, but rather the X-ray beam is more attenuated in this region because of the longer path length of photons through the bony cortex on the periphery. Circular, fluid-filled shaped structure appears much like inflated balloon. Most commonly seen in follicular cysts on occlusal radiographs [1] [Figure 1].
Figure 1: Expansion of buccal cortical plate in periapical giving balloon-like appearance

Click here to view

Copper beaten skull/beaten silver appearance/thumb print appearance

The growing brain exerts a pulsatile pressure on the malleable cranium, producing a gyral pattern/convoluted markings evidenced on plain skull X-rays known as copper-beaten skull appearance. Evident in patients with Crouzon syndrome, hypophosphatasia, craniosynostosis, and obstructive hydrocephalus on the lateral skull and postero-anterior view. Currently, it is widely considered to be a reflection of normal brain growth, without pathological significance. The markings are most prominent during periods of rapid brain growth, between age 2-3 years and 5-7 years. They become less prominent after approximately 8 years of age [2] [Figure 2].
Figure 2: Lateral cephalogram showing copper beaten appearance on skull

Click here to view

Codman's triangle

It's a triangular area of new subperiosteal bone that is created when a lesion, often a tumor, raises the periosteum away from the bone. A Codman triangle is not actually a full triangle. Instead, it is often a pseudotriangle on radiographic findings with ossification on the original bone and one additional side of the triangle which forms a two-sided triangle with one open side. This two-sided appearance is generated due to a tumor (or growth) that is growing at a rate which is faster than the periosteum can grow or expand, so instead of dimpling, the periosteum tears away, and provides ossification on the second edge of the triangle. Seen on occlusal radiographs in cases of alveolar bone carcinoma, osteogenic sarcoma, Ewing's sarcoma, etc., [3] [Figure 3].
Figure 3: Codman's triangle in a patient with carcinoma of alveolar ridge

Click here to view

Driven snow appearance

Mixed radiolucent and radiopaque lesion appears as driven snow, and it's a characteristic of Calcifying epithelial odontogenic cyst (CEOC) in which the radiopaque flecks align near the crown of the involved impacted teeth. [4]

Downward bowing

The lesions that invade to the inferior border of the mandible when their size reaches a limit that often demonstrates a characteristic downward bowing of the inferior cortex of the mandible. It has a centrifugal growth pattern rather than a linear one, revealing equal expansion in all directions as a round tumor mass. It's most commonly evident in cases of cemento-ossifying fibroma and ameloblastoma [5] [Figure 4].
Figure 4: Downward bowing in a patient with ameloblastoma

Click here to view

Floating teeth

It is a result of alveolar bone destruction around the root of the teeth giving the appearance of a floating tooth on the X-ray. Seen in cases of histiocytosis X, severe periodontitis, malignant lymphoma, and other malignant diseases [6],[7] [Figure 5].
Figure 5: Orthopantomograph showing floating teeth in a case with periodontitis

Click here to view

Ground glass appearance

Ground glass is glass whose surface has been ground to produce a flat but rough (matte) finish. In radiology, it's a lucent lesion, with endosteal scalloping, with or without bone expansion, and the absence of periosteal reaction, usually the matrix of the lucency is smooth and relatively homogeneous; classically, this finding is described as a ground-glass appearance. Irregular areas of sclerosis may be present with or without calcification. The lucent lesion has a thick sclerotic border. Evident in cases of fibrous dysplasia, paget's disease, hyperpararthyroidism, and ossifying fibroma [8] [Figure 6].
Figure 6: Ground glass appearance of a case of ossifying fibroma on maxillary tuberosity region

Click here to view

Ghost teeth

In the cases of regional odontodysplasia, there is thinning of enamel and dentin layers, with wide pulp chambers. This gives a typical ghost teeth appearance, formed due to lack of contrast between enamel and dentin, both of which are less radiopaque than uneffected counterparts. Teeth appear more radiolucent than normal [9] [Figure 7].
Figure 7: Ghost like appearance of teeth in patient with regional odontodysplasia

Click here to view

Honey comb pattern

A radiographic appearance present in radiolucent multilocular lesions, whose compartments are small and tend to be uniform in size like in honey bees comb. Evident in cases of CEOC, hemangioma, central giant cell granuloma, keratocystic odontogenic tumor, and ameloblastoma. [10]

Hair on end appearance

It results from a periosteal reaction manifesting as perpendicular trabeculations interspersed by radiolucent marrow hyperplasia along the skull vault. There is hyperplasia of bone marrow at the expense of cancellous bone. The extent of bone changes relates to the degree of this hyperplasia. It is a characteristic appearance in cases with sickle cell anemia and thalassemia. [11]

Heart shaped radiolucency

In the maxillary central incisor region, anterior nasal spine comes over cystic radiolucency giving it a typical heart shape, and it's a characteristic sign for nasopalatine cyst [12],[13] [Figure 8].
Figure 9: Cropped panoramic image showing moth-eaten appearance in a patient with carcinoma of alveolar ridge

Click here to view

Moth eaten appearance

Its ill-defined, noncorticated radiolucency with ragged borders giving the appearance as eaten by a moth. Noticed in early stages of osteosarcoma, squamous cell carcinoma, osteomyelitis, osteoradionecrosis, leukemia, malignant lymphoma, etc., [14] [Figure 9].{Figure 9}

Mottled appearance

Mottle or mottling is the appearance of uneven spots. In radiology, it is a mixed lesion with patchy radiolucency and interspersed opacities in it. Seen in cases of fibrous dysplasia, ossifying fibroma, Paget's disease, etc. [15]

Onion skin appearance

Lamellated periosteal reaction in which multiple concentric layers of new bone are laid down, giving the appearance of multiple skins of an onion. Noticed in patients with acute osteomyelitis, osteosarcoma, Ewing's tumor, and eosinophilic granuloma. [16]

Punched out radiolucency

Multiple lytic lesions, that is, with the local disappearance of normal bone due to resorption giving a punched out pattern. Most commonly seen in cases of multiple myeloma and langerhans cell histiocytosis [6] [Figure 10].
Figure 10: Multiple punched out radiolucencies in patient with histiocytosis X

Click here to view

Root less teeth: Teeth without the formation of complete roots and its characteristic feature of Type I dentin dysplasia [17] [Figure 11].
Figure 11: Panoramic image showing rootless teeth in case of dentin dysplasia

Click here to view

Step ladder appearance

The medullary bone of jaws becomes most visible as horizontal trabeculations that create step ladder pattern. Evident in cases of sickle cell anemia and normal mandibular alveolar bone. [18]

Sun ray/sunburst appearance

If the lesion grows rapidly but steadily, the periosteum will not have enough time to lay down thin shell of bone, and in such cases, the tiny fibers that connect the periosteum to the bone (Sharpey's fibers) become stretched out perpendicular to the bone. When these fibers ossify, they produce a pattern sometimes called "sunburst" periosteal reaction. Noticed in cases of osteosarcoma, hemangioma, and osteoblastoma [19] [Figure 12].
Figure 12: Cropped panoramic image showing sunray pattern in a patient with Ewing sarcoma

Click here to view

Soap bubble appearance

A radiographic appearance present in radiolucent multilocular lesions, consisting of circular compartments of varying size, and appear to somewhat overlap. Evident in cases of ameloblastoma, aneurysmal bone cyst, and central hemangioma [20] [Figure 13].
Figure 13: Cropped panoramic image showing soap bubble appearance in a case of keratocystic odontogenic tumor

Click here to view

Tennis racket appearance

A radiographic appearance present in radiolucent multilocular lesions composed of angular compartments that result from the development of less or more straight septa and it is a characteristic of odontogenic myxoma. [21]

  Conclusion Top

Some radiographic patterns are pathogonomic and characteristic to a specific disease and thus can be used for narrowing the differential diagnosis and thereby helping the new budding doctors for radiodiagnosis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

White SC, Pharoah MJ. Imaging principles and techniques. Oral Radiology - Principles and Interpretation. 6 th ed., Ch. 4. Indian Reprint, 2011, ISBN: 978-81-312-1977-5: Projection Geometry Mosby Elsevier; 2011. p. 51-2.   Back to cited text no. 1
Vela Desai, Smita RP, Rajeev S. Copper Beaten Skull! Can it be a usual apperance? Int J Clin Pediatr Dent. 2014;7:47-9.  Back to cited text no. 2
Anitha B, Winnifred C, Sumathy C, Kannan A. Osteosarcoma of mandible: A case report and review of literature. J Clin Diagn Res 2012;6 Suppl 2:753-7.  Back to cited text no. 3
Misra SR, Lenka S, Sahoo SR, Mishra S. Giant pindborg tumor (calcifying epithelial odontogenic tumor): An unusual case report with radiologic-pathologic correlation. J Clin Imaging Sci 2013;3 Suppl 1:11.  Back to cited text no. 4
Neyaz Z, Gadodia A, Gamanagatti S, Mukhopadhyay S. Radiographical approach to jaw lesions. Singapore Med J 2008;49:165-76.  Back to cited text no. 5
Jayachandran S, Balaji N. Langerhans cell histiocytosis. World J Dent 2011;2:57-62.  Back to cited text no. 6
Lee BD, Lee W, Lee J, Son HJ. Eosinophilic granuloma in the anterior mandible mimicking radicular cyst. Imaging Sci Dent 2013;43:117-22.  Back to cited text no. 7
Collins J, Stern EJ. Ground-glass opacity at CT: The ABCs. AJR Am J Roentgenol 1997;169:355-67.  Back to cited text no. 8
Magalhães AC, Pessan JP, Cunha RF, Delbem AC. Regional odontodysplasia: Case report. J Appl Oral Sci 2007;15:465-9.  Back to cited text no. 9
Mittal A, Soheyl AS, Vinod VC, Garg P. Images: Central hemangioma of maxilla. Indian J Radiol Imaging 2007;17:163-5.  Back to cited text no. 10
  Medknow Journal  
Ghosh S, Wadhwa P, Kumar A, Pai K, Seshadri S, Manohar C. Abnormal radiological features in a multiple myeloma patient: A case report and radiological review of myelomas. Dentomaxillofac Radiol 2011;40:513-8.  Back to cited text no. 11
Escoda Francolí J, Almendros Marqués N, Berini Aytés L, Gay Escoda C. Nasopalatine duct cyst: Report of 22 cases and review of the literature. Med Oral Patol Oral Cir Bucal 2008;13:E438-43.  Back to cited text no. 12
Fating C, Gupta R, Lanjewar M, Nayak B, Bakshi A, Diwan R. Nasopalatine duct cyst: A rare case report. Chattisgarh J Health Sci 2013;1:103-6.  Back to cited text no. 13
Malik R, Misra D, Misra A. Asymptomatic, expansive, unilateral multilocular radiolucency with moth eaten appearance of body of mandible. Int J Dent Case Rep 2011;1:101-6.  Back to cited text no. 14
Araki M, Matsumoto K, Matsumoto N, Honda K, Ohki H, Komiyama K. Unusual radiographic appearance of ossifying fibroma in the left mandibular angle. Dentomaxillofac Radiol 2010;39:314-9.  Back to cited text no. 15
Wang CL, Yacobi R, Pharoah M, Thorner P. Ewing′s sarcoma: Metastatic tumor to the jaw. Oral Surg Oral Med Oral Pathol 1991;71:597-602.  Back to cited text no. 16
Fulari SG, Tambake DP. Rootless teeth: Dentin dysplasia type I. Contemp Clin Dent 2013;4:520-2.  Back to cited text no. 17
[PUBMED]  Medknow Journal  
White SC, Pharoah MJ. Systemic diseases manifested in the jaws. Oral Radiology - Principles and Interpretation. 6 th ed., Ch. 25.  philadelphia: Mosby Elsevier Publications; 2011. p. 468-9.  Back to cited text no. 18
Mohammadi A, Ilkhanizadeh B, Ghasemi-Rad M. Mandibular plasmocytoma with sun-ray periosteal reaction: A unique presentation. Int J Surg Case Rep 2012;3:296-8.  Back to cited text no. 19
Fan X, Qiu W, Zhang Z, Mao Q. Comparative study of clinical manifestation, plain-film radiography, and computed tomographic scan in arteriovenous malformations of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:503-9.  Back to cited text no. 20
Vijayalaxmi D, Murali S, Sekar B. Odontogenic myxoma - An unusual presentation. JIADS 2011;2:48-51.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Radiographic Signs
Article Figures

 Article Access Statistics
    PDF Downloaded1980    
    Comments [Add]    

Recommend this journal