Indian Journal of Health Sciences and Biomedical Research KLEU

: 2015  |  Volume : 8  |  Issue : 2  |  Page : 85--90

Dental radiographic signs

Swati Phore1, Rahul Singh Panchal2, Pallavi Baghla3, Nuzhat Nabi1,  
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

Correspondence Address:
Swati Phore
Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan


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.

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

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Phore S, Panchal RS, Baghla P, Nabi N. Dental radiographic signs. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2022 Jan 17 ];8:85-90
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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

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}

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}

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}

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}

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}

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}

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}

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}

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}

Root less teeth: Teeth without the formation of complete roots and its characteristic feature of Type I dentin dysplasia [17] [Figure 11].{Figure 11}

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}

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}

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]


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.

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Conflicts of interest

There are no conflicts of interest.


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