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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 462-465

Soft tissue calcifications in the head and neck region: A CBCT based retrospective study

1 Department of Oral Medicine and Radiology, Faculty of Dentistry, Meenakshi Academy of Higher Education and Research, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
2 Department of Dentistry, Sri Muthukumaran Medical College, Hospital and Research Institute, Mangadu, Chennai, Tamil Nadu, India

Date of Submission01-Feb-2021
Date of Decision18-Nov-2022
Date of Acceptance22-Nov-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
B G Harsha Vardhan
Meenakshi Ammal Dental College, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_32_21

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Background: Soft tissue calcifications are most commonly seen in two-dimensional radiographs. Some may be physiological, and some may be pathological and need treatment. CBCT images provide valuable information about anatomic structures and pathologies. These soft tissue calcifications can be seen clearly in CBCT without superimposition and can be diagnosed appropriately. Aim and Objectives: This study aimed to assess the type and prevalence of calcifications found in CBCT volumes obtained for various diagnostic purposes. The objective of the present study was to determine the prevalence of soft tissue and to find their anatomic location, size, and type as well as their relation to age and gender. Materials and Method: Three hundred full-skull CBCT volumes were retrieved retrospectively from the age-group of 9–75 yrs and were evaluated for calcifications. The study sample included CBCT volumes taken for all diagnostic purposes, and those which contained artifacts were excluded. Results: Of 300 CBCT volumes, 133 were females, and 167 were males. Among them, 446 calcifications were encountered in 177 individuals. Their distribution was pineal gland calcification (24.8%), tonsillolith (18%), choroid plexus calcification (24%), pulp stone (12.4%), calcified stylohyoid chain (8%), sialolith (4%), triticeous cartilage calcification (2%), phlebolith (3%), and extracranial carotid artery calcification (1%). Conclusion: Although most of the calcifications are asymptomatic and require no treatment, correct identification of these findings will reduce further diagnostic assessment and provide more appropriate treatment plans. It will also provide the ability to evaluate underlying diseases comprehensively, and practitioners will have life-saving information by early diagnosis.

Keywords: Cone beam computed tomography, soft tissue calcifications
Key Message: Clinicians should be aware of the prevalence of calcified lesions, which may or may not require intervention.

How to cite this article:
Vardhan B G, Gopal K S, Ganesh M R, Nagammai N, Siddique A. Soft tissue calcifications in the head and neck region: A CBCT based retrospective study. J Indian Acad Oral Med Radiol 2022;34:462-5

How to cite this URL:
Vardhan B G, Gopal K S, Ganesh M R, Nagammai N, Siddique A. Soft tissue calcifications in the head and neck region: A CBCT based retrospective study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Jan 28];34:462-5. Available from: http://www.jiaomr.in/text.asp?2022/34/4/462/363032

   Introduction Top

Ossification is depositing new bone material by cells called osteoblasts—heterotopic ossification results in bone tissue often atypical at an extraskeletal location. Calcification is often confused with ossification. Calcification is synonymous with forming calcium-based salts and crystals within cells and tissue. It is a process that occurs during ossification, but not necessarily vice versa.[1]

There are three types of heterotopic calcifications. Dystrophic calcifications represent the deposition of calcium salts in an unorganized fashion within the dead tissue with normal serum calcium and phosphate levels. In the metastatic type, the minerals are precipitated in soft tissues due to increased calcium and phosphorus serum levels. Idiopathic type constitutes the precipitation of minerals in soft tissues despite normal calcium and phosphorus levels.[2]

Calcifications are detected accidentally in the head and neck region on panoramic and cone beam computed tomography (CBCT) during routine radiographic examinations.[3] They may vary according to number, anatomic location, size, and distribution. These are usually asymptomatic. Though these calcifications may be detected more commonly on panoramic radiographs, many structures in the head and neck region are close to one another, making localization and identification difficult. In addition, detection and confirmation are complicated on conventional extra-oral dental images because most radiographic images in dentistry are planar, providing a two-dimensional (2-D) representation of a three-dimensional (3-D) object. This potentially results in the inaccurate analysis of various calcifications on conventional images. With the rapid adoption of cone beam computed tomography imaging in dental practice and research, providing information regarding its presence will aid the clinician in a definite diagnosis and an appropriate treatment plan. In the past, two-dimensional evaluations of these calcified structures were reported by many workers.[1],[3] With technological advancements, cone beam computed tomography (CBCT) provides a better and a precise visualization of these structures, which aids in the management.[3]

Therefore, it was decided to assess the prevalence of soft tissue calcifications in the maxillofacial region using CBCT.

   Materials and Method Top

The descriptive retrospective study evaluated 300 full-skull CBCT volumes of patients presenting to the department from June 2016 to February 2019. The radiographs were taken for different reasons and were retrieved from the archives. Ethical clearance was obtained from the Institutional Review Board of Meenakshi Ammal Dental College on March 12 2019, and the ethical clearance number was MADC/IRB-XXVIII/2019/436. All scans were acquired in an upright standing position using a Planmeca ProMax CBCT machine, and the imaging parameters were set at 120 kVp, 18.66 mA, scan time 20 seconds, resolution 0.4 mm, and 16 x16 cm field of view. All the volumes were analyzed using Planmeca Romexis software in all three orthogonal sections in a quiet environment with subdued lighting in a LED monitor at a comfortable distance from the screen to evaluate soft tissue calcification in the head and neck region. G power software was used for calculating the statistical power of the study. It showed that 150 samples could be used to obtain the study's significance. Two observers participated in the study. The interobserver and intra-observer reliability was assessed in 10 cases and found to be good. The presence of pineal gland calcification (PGC), tonsilloliths, choroid plexus calcification (CPC), pulp stones, calcified stylohyoid chain (CSC), sialoliths, triticeous cartilage calcification (TCC), phleboliths, and extracranial carotid artery calcification (ECCAC) was evaluated.

Statistical analysis

The data were analyzed using IBM SPSS Software Version 23.0 Chicago. The standard descriptive methods were applied to determine the characteristics of the sample. The Chi-square test, Fisher's exact test, and Kappa test were used to compare the categorical demographic variables among the groups. The confidence interval was set to 95%, and P < 0.005 was considered statistically significant.

   Results Top

In the study group of 300 samples, the total number of males was 167 (55.7%) and females was 133 (44.3%). The age of the study population ranged from 9 to 75 years, with a mean age of 32.76 years. The total number of calcifications that were present was 446. One or more calcifications were identified in 177 (59%) samples. A total of 123 (41%) CBCT volumes did not show evidence of any calcification. Among 446 calcifications, the distribution of each calcification genderwise and in total is given in [Table 1] and [Graph 1]. PGC is the most frequently encountered calcification among CBCT volumes of the study population, whereas ECCAC and TCC were identified in the least number. Except in phlebolith and TCC, females presented with more numbers of calcifications. Both among males and females, PGC was most commonly seen. CBCT volumes of female patients did not show any phlebolith. Sialolith and ECCAC were absent in male patients.
Table 1: Genderwise distribution of calcifications

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   Discussion Top

Soft tissue calcifications in the maxillofacial area are uncommon and generally were identified on a routine radiographic examination. However, some soft tissue calcifications may be serious and require treatment or follow-up of the underlying cause. The anatomic location, number, distribution, and pattern of the calcifications are important interpretative criteria in radiographic evaluation of soft tissue opacities.

The deposition of calcium salts, primarily calcium phosphate, usually occurs in the skeleton. When it occurs in an unorganized fashion in soft tissue, it is referred to as heterotopic calcification. This soft tissue mineralization may develop in a wide variety of unrelated disorders and degenerative processes. Heterotopic calcifications may be divided into three categories: dystrophic calcification, idiopathic calcification, and metastatic calcification.[4]

CBCT, introduced in 1998, is increasingly used for 3-D imaging in maxillofacial radiology.[4] Larger scans provide a comprehensive radiologic view for implantology, orthodontics, maxillofacial surgery, and dentoalveolar pathology assessment. With the increasing use of CBCT imaging in dentistry, the incidental discovery of soft tissue calcifications is likely to increase. In addition, CBCT imaging provides images in the third dimension, facilitating precise localization. The clinician should have a solid foundation in understanding the radiographic presentation of the calcifications and their relationship to the various structures. CBCT imaging is an excellent diagnostic tool to determine calcification's size, location, and shape.[5]

Literature reports concerning calcifications had varied sample sizes ranging from 100 to 1000. Of the 300 samples of our study showed, only 177 volumes (59%) had one or more soft tissue calcifications which coincided with the study conducted by Lopes et al.[6] in 2017, which showed 56% of calcification, and Sevin Barghan et al.[7] in 2016 showed 67% of calcification. Other studies by Price JB et al.[8] in 2012 showed 46%, Ali Altındağ et al.[9] in 2017 showed 46.02%, and Veeratrishul Allareddy et al.[10] in 2012 showed 33%, which is a lesser incidence of calcification when compared with our study.

PGC had the highest percentage in our study (30%). The incidence of PGC in earlier studies ranged from as low as 4% in Rheem S et al. in 2013[11] to as high as 64% in Onofre et al. in 2021.[5] Several studies reported the incidence varying between 11 and 15% (Suhas P Pande et al. in 2015).[12] Interestingly, in a study by Veeratrishul Allareddy et al. in 2012,[10] PGC was the most common calcification with a low incidence of 14.7%.

CPC (24%) was the second commonest calcification that was encountered in our study, which was the highest among the studies conducted by Onofre et al. (1.7%),[5] Suhas P Pande et al. in 2015 (11%).[12] The least calcification that was identified was ECCAC (1%).

The incidence of tonsilloliths in our study was 18%. Other studies reported varied values—4.9% (Price JB et al. in 2012),[8] 9.2% (Veeratrishul Allareddy et al. in 2012),[10] 10% (Pette et al. in 2012),[13] 33.2% (Onofre et al. in 2021),[5] 45.5% (Zahra Dalili Kajan et al. in 2016),[14] and 86% (Ali Altındağ et al. in 2017).[9] Pulp stones were noticed in 10% of our study population, and it was closer to a study conducted in the South Indian population by A. Fysal Yousuf et al. in 2018 (14.4%).[15] On the contrary, da Silva et al. in 2017[16] reported an incidence of 31.9%. The incidence of CSC and sialolith (8% and 4%) in our study matched studies done by Ali Altındağ et al. in 2017[9] (6% and 9%) and Santosh R Patil et al. in 2017 (4% and 8%).[17]

   Limitation Top

This study should be done with a large sample size.

   Conclusion Top

CBCT's capability to view structures three-dimensionally facilitates the identification of soft tissue without any superimposition. The incidence of each calcification may vary according to ethnicity, race, geographic location, and gender.[18] Clinicians should be aware of these incidentally discovered calcified lesions, which may or may not require intervention. Identifying these findings in CBCT will reduce further diagnostic evaluation and provide more appropriate treatment plans. The identification of ECCAC or intracranial calcification, in particular, will provide important life-saving information through its early diagnosis.[19]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Saati S, Foroozandeh M, Alafchi B. Radiographic characteristics of soft tissue calcification on digital panoramic images. Pesquisa Brasileira em Odontopediatria e Clínica Integrada 2020;20:e5053.  Back to cited text no. 1
Pauwels R, Araki K, Siewerdsen JH, Thongvigitmanee SS. Technical aspects of dental CBCT: State of the art. Dentomaxillofac Radiol 2015;44:20140224.  Back to cited text no. 2
Takeshita WM, Vessoni Iwaki LC, Da Silva MC, Tonin RH. Evaluation of diagnostic accuracy of conventional and digital periapical radiography, panoramic radiography, and cone-beam computed tomography in assessing alveolar bone loss. Contemp Clin Dent 2014;5:318–23.  Back to cited text no. 3
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Yılmaz F, Kamburoglu K, Yeta NY, Öztan MD. Cone beam computed tomography aided diagnosis and treatment of endodontic cases: Critical analysis. World J Radiol 2016;8:716-25.  Back to cited text no. 4
de Onofre NM, Vizzotto MB, Wanzeler AM, da Silveira Tiecher PF, Arús NA, Guillén LE, et al. Association between internal carotid artery calcifications detected as incidental findings and clinical characteristics associated with atherosclerosis: A dental volumetric tomography study. Eur J Radiol 2021;145:110045.  Back to cited text no. 5
Lopes IA, Tucunduva RM, Handem RH, Capelozza AL. Study the frequency and location of incidental findings of the maxillofacial region in different fields of view in CBCT scans. Dentomaxillofac Radiol 2017;46:20160215.  Back to cited text no. 6
Barghan S, Tahmasbi Arashlow M, Nair MK. Incidental findings on cone beam computed tomography studies outside of the maxillofacial skeleton. Int J Dent 2016;2016:9196503.  Back to cited text no. 7
Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: A descriptive retrospective study. Clin Oral Implants Res 2012;23:1261-8.  Back to cited text no. 8
Altındağ A, Avsever H, Borahan O, Akyol M, Orhan K. Incidental findings in cone-beam computed tomographic images: Calcifications in head and neck region. Balk J Dent Med 2017;21:100-7.  Back to cited text no. 9
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Rheem S, Nielsen IL, Oberoi S. Incidental findings in the maxillofacial region identified on cone-beam computed tomography scans. J Orthod 2013;1:33-9.  Back to cited text no. 11
Pande SP, Kumbhare SP, Parate AR. Incidental findings on cone beam computed tomography: Relate and relay. J Indian Acad Oral Med Radiol 2015;27:48-54.  Back to cited text no. 12
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Pette GA, Norkin FJ, Ganeles J, Hardigan P, Lask E, Zfaz S, et al. Incidental findings from a retrospective study of 318 cone beam computed tomography consultation reports. Int J Oral Maxillofac Implants 2012;27:595-603.  Back to cited text no. 13
Kajan ZD, Sigaroudi AK, Mohebbi M. Prevalence and patterns of palatine and adenoid tonsilloliths in cone-beam computed tomography images of an Iranian population. Dent Res J (Isfahan) 2016;13:315–21.  Back to cited text no. 14
Yousuf MA, Antony S. Radiographic assessment of prevalence of pulp stones in South Indian population. Drug Invention Today 2018;10:3162-5.  Back to cited text no. 15
da Silva EJ, Prado MC, Queiroz PM, Nejaim Y, Brasil DM, Groppo FC, et al. Assessing pulp stones by cone-beam computed tomography. Clin Oral Investing 2017;21:2327-33.  Back to cited text no. 16
Patil SR, Alam MK, Moriyama K, Matsuda S, Shoumura M, Osuga N. 3D CBCT assessment of soft tissue calcification. J Hard Tissue Biol 2017;26:297-300.  Back to cited text no. 17
Togan B, Gander T, Lanzer M, Martin R, Lübbers HT. Incidence and frequency of nondental incidental findings on cone-beam computed tomography. J Craniomaxillofac Surg 2016;44:1373-780.  Back to cited text no. 18
Khojastepour L, Haghnegahdar A, Sayar H. Prevalence of soft tissue calcifications in CBCT images of mandibular region. J Dent (Shiraj) 2017;18:88-94.  Back to cited text no. 19


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