Dental MCQ
Normal landmarks versus pathology · Head & Neck · INBDE Patient Cases

Radiographic Anatomy INBDE Patient Cases

By Dr. Isaac Sun, DDS

12 ADA INBDE-format patient cases on radiographic anatomy. Each case is a shared patient box (chief complaint, history, medications, allergies, exam) followed by linked multiple-choice questions with full distractor explanations. Practice the way the real exam is structured.

12 patient cases60 linked questionsADA INBDE formatFull distractor explanations

Twelve ADA INBDE-format patient cases on reading periapical, bitewing, and panoramic radiographs and telling normal anatomy and image artifacts apart from pathology. Cases include the mental foramen mimicking a periapical lesion, the maxillary sinus floor over a molar apex and oroantral communication, the inferior alveolar canal and Rood signs before third molar extraction, the inverted Y of Ennis, the zygomatic process versus condensing osteitis, the nasopalatine foramen versus a nasopalatine duct cyst, a nutrient canal versus a vertical root fracture, a Stafne bone defect near the mandibular angle, coronoid process superimposition over the tuberosity, cervical burnout and the Mach band versus root caries, a panoramic ghost image, and an elongated styloid process (Eagle syndrome) versus carotid artery calcification.

Case Coverage Map
What each case is testing
Round radiolucency at a premolar apex:
Mental foramen versus a periapical lesion, vitality testing and parallax.
Sinus floor crossing an upper molar apex:
Maxillary sinus proximity and oroantral communication risk before extraction.
Canal crossing an impacted third molar root:
Inferior alveolar canal proximity, Rood signs, and nerve injury risk.
Y-shaped line above the upper anteriors:
Inverted Y of Ennis versus a fracture line, corticated borders.
J-shaped opacity over an upper molar apex:
Zygomatic process versus condensing osteitis, parallax shift.
Midline radiolucency between the upper centrals:
Nasopalatine foramen versus nasopalatine duct cyst, size and symptoms.
Vertical line beside a lower incisor:
Nutrient canal versus vertical root fracture, the isolated deep pocket clue.
Corticated radiolucency near the mandibular angle:
Stafne bone defect below the canal, CBCT confirmation.
Triangular opacity over the maxillary tuberosity:
Coronoid process superimposition, open versus closed mouth film.
Dark notches at the tooth necks on bitewings:
Cervical burnout versus root caries, the Mach band illusion.
Blurred opacity over the ramus on a panoramic:
Ghost image artifact, remove metal and retake.
Mineralized band from the skull base:
Elongated styloid (Eagle syndrome) versus carotid artery calcification.
Patient case: Round radiolucency at the apex of #28
0 of 5 answered, 0 correct
Patient
Female, 41 years old
Chief Complaint
"My old dentist said I might need a root canal on a lower tooth, but it has never hurt."
Background and/or Patient History
  • Recent PA from another office showing a round radiolucency at the apex of #28
  • No pain, swelling, or bite sensitivity
  • Otherwise healthy
Allergies
NKDA
Medications
  • None
Dental History
  • No restorations on #28
  • Routine recalls every 6 months
Current Findings
  • Tooth #28 non-carious
  • Vital to cold and EPT, comparable to #29 and #20
  • No percussion or palpation tenderness
  • PA: 4 mm well-defined oval radiolucency with a corticated border at the apex of #28
  1. Question 1
    Easy
    The radiolucency at the apex of #28 most likely represents the:
  2. Question 2
    Moderate
    The mental foramen transmits the:
  3. Question 3
    Moderate
    The finding that best distinguishes a mental foramen from a periapical lesion is:
  4. Question 4
    Moderate
    The most appropriate next step is to:
  5. Question 5
    Hard
    On the angled second PA, the mental foramen will:

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Patient case: Maxillary sinus floor crossing the apex of #14
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Patient
Male, 55 years old
Chief Complaint
"My upper left back tooth has a deep filling and my dentist said the root looks like it is in my sinus."
Background and/or Patient History
  • Evaluation of #14 with recurrent decay around a large MOD amalgam
  • No sinus symptoms
  • Well-controlled hypertension
Allergies
NKDA
Medications
  • Lisinopril 10 mg daily
Dental History
  • Large MOD amalgam on #14 placed 20 years ago
  • No prior endodontic treatment
Current Findings
  • Tooth #14 with recurrent caries under amalgam
  • Vital to cold but lingering
  • No percussion pain
  • No facial pressure, no nasal congestion, no drainage
  • PA: thin radiopaque line (sinus floor) crossing the palatal root apex of #14
  • Apex appears to project into the radiolucent sinus
  1. Question 1
    Easy
    The dark space above the apex of #14 on the PA represents the:
  2. Question 2
    Moderate
    The maxillary tooth whose roots most often project into the sinus is:
  3. Question 3
    Moderate
    On the 2D PA, the apex appears to extend into the sinus. The best way to assess the true 3D relationship is:
  4. Question 4
    Moderate
    If extraction of #14 is required, the most important risk to discuss with the patient is:
  5. Question 5
    Hard
    If an oroantral communication is suspected immediately after extraction, the best chairside test is:

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Patient case: IAC crossing the root of impacted #32
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Patient
Male, 26 years old
Chief Complaint
"My wisdom tooth on the lower right has been giving me trouble and I want it out."
Background and/or Patient History
  • Partially erupted, painful #32
  • Pre-extraction panoramic obtained
  • Otherwise healthy
Allergies
NKDA
Medications
  • None
Dental History
  • Wisdom teeth never extracted
  • Episodes of pericoronitis on #32 over the past year
Current Findings
  • Partially erupted #32 with inflamed operculum
  • Mild trismus
  • Normal lower lip sensation bilaterally
  • Pano: mesioangular impaction of #32
  • Radiolucent band of the IAC crosses the root
  • Darkening of the root over the canal
  • Loss of the superior cortical line of the canal at the crossing point
  1. Question 1
    Easy
    The radiolucent band with corticated borders crossing the root of #32 on the pano represents the:
  2. Question 2
    Easy
    The inferior alveolar nerve is a branch of which division of the trigeminal nerve?
  3. Question 3
    Moderate
    Which radiographic sign on the pano is the strongest predictor of IAN injury during extraction of #32?
  4. Question 4
    Moderate
    The best next imaging step before proceeding with extraction is:
  5. Question 5
    Hard
    If the patient sustains a paresthesia of the lower lip and chin after extraction, the most appropriate immediate management is:

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Patient case: Y-shaped radiopacity above the central incisors
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Patient
Female, 30 years old
Chief Complaint
"My new dentist saw a Y-shape on my X-ray and I want to make sure it isn't a fracture."
Background and/or Patient History
  • New-patient exam
  • Maxillary anterior PA shows a Y-shaped radiopaque line above the central incisors and canine region
  • No trauma history, no nasal symptoms, no pain
Allergies
NKDA
Medications
  • Oral contraceptive
Dental History
  • No prior restorations
  • Regular recalls
Current Findings
  • Class I occlusion
  • All maxillary anterior teeth vital and non-carious
  • No swelling
  • No palatal expansion
  • PA: well-defined Y-shaped radiopaque line above the canine-premolar area
  • Two arms of the Y diverge superiorly
  1. Question 1
    Easy
    The Y-shaped radiopaque line on the periapical represents the:
  2. Question 2
    Moderate
    The two structures whose junction forms the inverted Y are:
  3. Question 3
    Moderate
    The finding that most reliably argues against a fracture in this case is:
  4. Question 4
    Easy
    The appropriate management for this finding is:
  5. Question 5
    Hard
    A second radiopaque horizontal line seen above the central incisor apices on the same PA most likely represents the:

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Patient case: J-shaped opacity surrounding the apex of #14
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Patient
Male, 48 years old
Chief Complaint
"My upper back tooth has a bright halo around the root on the X-ray. Is that bad?"
Background and/or Patient History
  • New PA shows a dense J-shaped radiopaque shadow surrounding the buccal root of #14
  • No pain, swelling, facial pressure, or biting sensitivity
  • Otherwise healthy
Allergies
NKDA
Medications
  • None
Dental History
  • Conservative occlusal composite on #14 placed 5 years ago
Current Findings
  • Tooth #14 with a small intact occlusal composite
  • Vital to cold and EPT
  • No percussion or palpation tenderness
  • PA: J- or U-shaped dense radiopacity overlying and apparently encircling the buccal root of #14
  1. Question 1
    Easy
    The J-shaped radiopaque shadow over the apex of #14 most likely represents the:
  2. Question 2
    Moderate
    The clinical finding that best argues against condensing osteitis is:
  3. Question 3
    Moderate
    The best chairside technique to confirm that the opacity is a superimposed structure and not attached to the root is:
  4. Question 4
    Moderate
    The zygomatic process of the maxilla articulates with the:
  5. Question 5
    Hard
    The appropriate management plan for #14 is:

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Patient case: Midline radiolucency between the maxillary central incisors
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Patient
Male, 52 years old
Chief Complaint
"There's a round dark spot between my top front teeth on the X-ray. My last dentist never mentioned it."
Background and/or Patient History
  • New-patient comprehensive exam with full-mouth radiographs
  • No pain, swelling, or drainage
  • No history of trauma to the anterior maxilla
Allergies
NKDA
Medications
  • Atorvastatin 20 mg daily
Dental History
  • Small composite restorations on #8 and #9
  • Regular recalls
Current Findings
  • Teeth #8 and #9 vital to cold and EPT
  • No buccal or palatal swelling
  • Lamina dura intact around both central incisors
  • PA: well-defined oval, faintly heart-shaped radiolucency about 5 mm between the roots of #8 and #9, at the midline
  1. Question 1
    Easy
    The midline radiolucency between #8 and #9 most likely represents the:
  2. Question 2
    Moderate
    The nasopalatine foramen transmits the nasopalatine nerve and vessels, which supply the:
  3. Question 3
    Moderate
    Which feature would most increase concern that this is a nasopalatine duct cyst rather than a normal foramen?
  4. Question 4
    Moderate
    The most appropriate management for this 5 mm asymptomatic midline radiolucency is:
  5. Question 5
    Hard
    At a recall two years later the radiolucency has grown to 9 mm, the patient reports midline palatal swelling, and both incisors remain vital. The best next step is:

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Patient case: Vertical radiolucent line beside a mandibular incisor
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Patient
Female, 67 years old
Chief Complaint
"I'm worried about a crack in the bone between my lower front teeth on the X-ray."
Background and/or Patient History
  • Periodontal maintenance visit
  • Generalized mild horizontal bone loss
  • No pain or mobility of the lower incisors
Allergies
NKDA
Medications
  • Amlodipine 5 mg daily
  • Multivitamin
Dental History
  • No restorations on the lower anterior teeth
  • History of periodontal therapy
Current Findings
  • Lower incisors vital and non-mobile
  • No isolated deep probing depths
  • PA: thin vertical radiolucent line in the interdental bone beside the mandibular incisors, with faint radiopaque borders
  • Adjacent teeth non-restored and asymptomatic
  1. Question 1
    Easy
    The thin vertical radiolucent line in the interdental bone is most consistent with a:
  2. Question 2
    Moderate
    Nutrient canals are more frequently visible in which situation?
  3. Question 3
    Moderate
    Which finding would most strongly point to a true vertical root fracture instead of a nutrient canal?
  4. Question 4
    Moderate
    The appropriate management for this asymptomatic vital patient is:
  5. Question 5
    Hard
    If one of these teeth were instead a crowned, endodontically treated incisor with a sudden isolated 9 mm pocket and a halo radiolucency, the most likely diagnosis and step would be:

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Patient case: Corticated radiolucency below the canal near the mandibular angle
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Patient
Male, 58 years old
Chief Complaint
"My dentist found a dark area near the back corner of my lower jaw and I'm scared it's a tumor."
Background and/or Patient History
  • Panoramic taken for implant planning in the lower left
  • Incidental well-defined radiolucency near the right mandibular angle
  • No pain, swelling, numbness, or expansion
Allergies
Penicillin
Medications
  • Metformin 500 mg twice daily
Dental History
  • Lost lower left molars years ago
  • No problems on the right side
Current Findings
  • No facial asymmetry or swelling
  • Normal lip and tongue sensation
  • Teeth in the area vital
  • Pano: well-defined, corticated, round radiolucency below the inferior alveolar canal, between the canal and the inferior border, near the right angle
  • No root resorption or tooth displacement
  1. Question 1
    Easy
    A well-defined corticated radiolucency below the inferior alveolar canal near the angle, with vital teeth and no symptoms, most likely is a:
  2. Question 2
    Moderate
    The position of a Stafne defect below the inferior alveolar canal reflects that it is a depression on which surface of the mandible?
  3. Question 3
    Moderate
    The single best way to confirm the lingual location and avoid biopsy of a suspected Stafne defect is:
  4. Question 4
    Moderate
    The appropriate management of a classic asymptomatic Stafne defect is:
  5. Question 5
    Hard
    Which feature, if present, would argue against a simple Stafne defect and prompt biopsy or referral?

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Patient case: Triangular radiopacity over the maxillary tuberosity
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Patient
Male, 29 years old
Chief Complaint
"There's a triangle of bone over my upper back tooth area on the X-ray. Is something growing there?"
Background and/or Patient History
  • Periapical of the upper right molars taken with the mouth wide open for film placement
  • Triangular radiopacity over the tuberosity and third molar region
  • No pain, swelling, or trismus
Allergies
NKDA
Medications
  • None
Dental History
  • Erupting upper third molars
  • No restorations in the area
Current Findings
  • No intraoral swelling or expansion of the tuberosity
  • Upper molars vital and non-tender
  • PA (mouth open): well-defined triangular radiopacity superimposed over the maxillary tuberosity region
  • Opacity absent on a film taken with the mouth closed
  1. Question 1
    Easy
    The triangular radiopacity over the tuberosity, present only when the mouth is open, represents the:
  2. Question 2
    Moderate
    The coronoid process is the attachment site for which muscle?
  3. Question 3
    Moderate
    The simplest way to confirm that the radiopacity is the coronoid process and not a maxillary lesion is to:
  4. Question 4
    Moderate
    The appropriate management is:
  5. Question 5
    Hard
    A true expansile radiopaque mass of the maxillary tuberosity that persists on a closed-mouth film, with buccal expansion, would instead warrant:

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Patient case: Radiolucent notches at the tooth necks on bitewings
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Patient
Female, 34 years old
Chief Complaint
"The new dentist's X-rays show dark notches on the sides of several teeth. Do I have a lot of cavities?"
Background and/or Patient History
  • Routine bitewings at a recall
  • Low caries risk with good home care
  • No sensitivity or food trapping
Allergies
NKDA
Medications
  • None
Dental History
  • A few small composite restorations
  • No recent caries
Current Findings
  • Symmetric V-shaped radiolucencies at the cervical regions of multiple posterior teeth, between the enamel edge and the alveolar crest
  • Tooth surfaces intact and hard to the explorer
  • No cavitation or soft spots
  • Radiolucencies have diffuse, even borders and a consistent appearance tooth to tooth
  1. Question 1
    Easy
    The symmetric V-shaped radiolucencies at the cervical regions of multiple teeth, with intact surfaces, are most consistent with:
  2. Question 2
    Moderate
    Cervical burnout arises because the cervical region is:
  3. Question 3
    Moderate
    Which feature would point to true root caries rather than burnout?
  4. Question 4
    Moderate
    The appropriate response to symmetric cervical burnout with intact surfaces is:
  5. Question 5
    Hard
    The radiolucent line sometimes perceived at the dentin side of a radiopaque restoration margin, where no true gap exists, is a related illusion called the:

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Patient case: Blurred radiopacity over the ramus on a panoramic
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Patient
Female, 45 years old
Chief Complaint
"The X-ray shows a big white blob over my jaw and I'm worried it's a growth."
Background and/or Patient History
  • Panoramic taken to evaluate a lower left wisdom tooth
  • A blurred radiopacity overlies the right ramus
  • Patient wore large hoop earrings during the exposure
Allergies
NKDA
Medications
  • Levothyroxine 75 mcg daily
Dental History
  • Retained lower wisdom teeth
Current Findings
  • No swelling, mass, or asymmetry of either ramus clinically
  • Both rami normal to palpation
  • Pano: ring-shaped radiopacity projected over the right ramus, higher and more blurred than the earrings seen on the left, sloping upward
  • No clinical sign of bony destruction or expansion
  1. Question 1
    Easy
    The blurred ring-shaped radiopacity over the right ramus, opposite the side of the earring, is best explained as a:
  2. Question 2
    Moderate
    A panoramic ghost image always appears:
  3. Question 3
    Moderate
    The simplest way to prevent this artifact is to:
  4. Question 4
    Moderate
    After recognizing the artifact, the appropriate step is to:
  5. Question 5
    Hard
    A different panoramic shows a radiopaque band crossing both rami at the same height with a midline notch. This most likely represents:

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Patient case: Mineralized band from the skull base on a panoramic
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Patient
Male, 50 years old
Chief Complaint
"I get a sharp pain in my throat and the side of my neck when I turn my head or swallow."
Background and/or Patient History
  • Referred by primary care after a normal throat exam
  • Pano taken to evaluate the molars also shows a long radiopaque band
  • Pain radiates to the ear, worse on head rotation and swallowing
Allergies
Sulfa
Medications
  • None
Dental History
  • Full dentition, no acute dental problems
Current Findings
  • No dental source of pain; teeth vital, no caries or periapical lesions
  • Tenderness on palpation of the tonsillar fossa
  • Pano: long mineralized band extending inferiorly from the temporal bone across the ramus toward the hyoid, bilaterally
  • No swelling or mass
  1. Question 1
    Easy
    The long mineralized band extending from the skull base toward the hyoid on the panoramic represents:
  2. Question 2
    Moderate
    The throat and neck pain on swallowing and head turning, with this finding, suggests:
  3. Question 3
    Moderate
    The elongated styloid produces these symptoms by irritating structures near which region?
  4. Question 4
    Moderate
    For this symptomatic patient, the dentist's most appropriate role is to:
  5. Question 5
    Hard
    If the same panoramic instead showed irregular radiopacities lateral to the cervical spine at the level of the hyoid in an older hypertensive patient, the priority concern would be:

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Radiographic Anatomy core recall

Refresh the anatomy facts these cases depend on: nerve numbers, foramina, functions, and lesion findings.

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