DENTASCAN IMAGING OF THE MANDIBLE

AND MAXILLA
Ken Yanagisawa, MD, Craig D. Friedman, MD, Eugenia M. Vining, MD,
and James J. Abrahams, MD

illa have included plain x-rays, tomograms, pan-

DentaScan is a unique new computer software program which
provides computed tomographic (CT) imaging of the mandible oramic radiography (panorex), computed tomo-
and maxilla in three planes of reference: axial, panoramic, and graphic (CT) scans, and, more recently, bone
oblique sagittal (or cross-sectional). The clarity and identical scans,' magnetic resonance imaging (MRI)
scale between the various views permits uniformity of measure- scans,' and three-dimensional reconstruction CT
ments and cross-referencing of anatomic structures through all
three planes. Unlike previous imaging techniques, the oblique
scans. Each of these modalities has shortcomings
sagittal view permits the evaluation of distinct buccal and lingual that limit their clinical utility.
cortical bone margins, as well as clear visualization of internal Dentascan is a CT computer software pro-
structures, such as the incisive and inferior alveolar canals. Sev- gram that produces multiple cross-referenced im-
eral case reports are presented to demonstrate the clinical use- ages of the jaw in the axial, cross-sectional, and
fulness of Dentascan.
panoramic views. Introduced in the mid-l980s, it
HEAD AND NECK 1993;15:1-7
0 1993 John Wiley & Sons, Inc. offers several significant improvements in the
evaluation of the osseous mandible and maxilla
and has been reported to be useful in head and
It has been previously difficult to precisely de- neck ~ u r g e r y . ~Through
-~ a series of case re-
termine the degree of disease or injury to the ports, we more clearly define the application and
mandible and maxilla using diagnostic imaging use of DentaScan in head and neck surgery.
techniques. In the case of oral cavity and oropha-
MATERIALS AND METHODS
ryngeal carcinoma, the presence and degree of
mandibular invasion has a great impact on Between January 1990 and June 1991, 30 pa-
treatment planning. Thus, accurate preoperative tients at Yale-New Haven Hospital (New Ha-
assessment of the mandible is essential. ven, CT) were selected in a nonconsecutive fash-
Methods of imaging the mandible and max- ion for this study. All had obvious or suggested
pathology involving the mandible and maxilla.
There were 15 cases of head and neck carcinoma,
From the Section of Otolaryngology-Head and Neck Surgery, and the eight cases of facial/mandibular trauma, and
Section of Neuroradiology, Department of Diagnostic Radiology. Yale seven cases of benign lesions, including amelo-
University School of Medicine, New Haven, Connecticut.
blastoma, keratocyst, oroantral fistula, osteora-
Address reprint requests to Dr. Friedman at the Section of Otolaryngol-
ogy. Department of Surgery, Yale University School of Medicine, Box
dionecrosis, and hemangioma. All patients had
3333, 333 Cedar Street, New Haven, CT 06510. pathologic confirmation of diagnosis based on the
Accepted for publication April 28. 1992 surgical specimen or biopsy.
CCC 0148-6403/93/0101-07
CT scans were obtained using dynamic scan-
0 1993 John Wiley & Sons, Inc ning mode on GE 9800 scanners with a 2-second

Dentascan Imaging HEAD & NECK January/February 1993 1

FIGURE 1. Axial CT image of the mandible using Dentascan.
The superimposed curved line defines the plane and location for
reformatting the panoramic image, and the numbered lines per- FIGURE 3. Oblique sagittal CT image of the mandible using
pendicular to this curve define the oblique sagittal images. Dentascan. Note the mental foramen in cross-section in frame
no. 25 (arrow).

scan time, 140 kV peak, and 70 mA. One-

millimeter axial sections were made of the man- side and botton of each image, and a millimeter
dible. Axial sections of 1.5 mm were made of the scale which allows accurate measurements."-A
maxilla. Using the Dentascan computer soft- The axial views are obtained in 1.0- to
ware program (General Electric Medical System, 1.5-mm intervals (Figure 1). Using one of these
Milwaukee, WI), images were reformatted into images, the CT technologist then places a series
panoramic and oblique sagittal views based on of points along the curve of the mandible or max-
the axial scans. illa using the cursor on the scanner console. The
DentaScan permits visualization of the man- computer joins these points to produce a smooth
dible and maxilla in three planes: axial, pan- curve, which is superimposed on the image of the
oramic, and oblique sagittal (cross-sectional) jaw. This line then defines the plane and location
(Figures 1-3). Axial CT scans are obtained in for reformatting the panoramic images. A series
the usual fashion a t intervals of 1.0 mm for the of lines perpendicular to this curve are then cre-
mandible, and 1.5 mm for the maxilla. An aver- ated by the computer a t intervals (usually 2 mm)
age mandibular scan requires 30-35 sections; a n to define the plane and location of the cross-
average maxillary scan, 20-30 sections. The sectional (oblique sagittal) images. These lines
computer program uses the data from the axial are numbered from right to left, allowing for
images to reformat new images in the panoramic easy identification of the corresponding num-
and oblique sagittal planes. Cross-referencing bered images.
anatomic structures in all three planes is easily Unlike the standard panorex film, the Den-
accomplished through a series of marks on the taScan panoramic views has no superimposition
of other osseous structures. The image quality is
sharp and clear and provides better tissue con-
trast resolution (Figure 2). Marks along the side
border of each panoramic frame correspond to
the axial slices from which the image was refor-
matted. The marks on the bottom border of each
frame correspond to the position of the cross-
sectional images. Anatomic structures such as
the inferior alveolar canal can be clearly visual-
ized.
The oblique sagittal view, or cross-sectional
view, is unique to Dentascan (Figure 3). Buccal
and lingual cortical margins can be clearly identi-
fied and evaluated, as can normal anatomic struc-
FIGURE 2. Panoramic Dentascan image of the mandible. Note tures, such as the inferior alveolar canal, the
the inferior alveolar canal (arrow). mental foramen, the mandibular foramen, the ge-

2 DentaScan Imaging HEAD K NECK JanuaryiFebruary 1993

nial tubercle, the greater and lesser palatine fora- Differentiation between buccal and lingual in-
men, the incisive canal, and the maxillary sinus. volvement was not possible with the other imag-
The marks along the side border again represent ing modalities. A rim mandibulectomy with pec-
the location of each axial image. The five marks toralis major myocutaneous flap reconstruction
along the bottom border of each frame depict was carried out. Of note, permanent sections of
the location of each panoramic image. the floor of mouth specimen revealed carcinoma in
situ and superficially invasive squamous cell car-
CASEREPORTS cinoma with clear margins. The patient did well
Case 1. A 60-year-old man with a history of ex- postoperatively without subsequent soft tissue
tensive alcohol and tobacco use presented with a breakdown.
TlNlMO stage 111 squamous cell carcinoma of
the floor of mouth. The patient was treated with Case 2. A 62-year-old woman was initially seen
excisional biopsy of a neck node and external- with a T4N2MO stage IV squamous cell carci-
beam radiotherapy to the oral cavity (5,400 cGy) noma of the left tonsil extending to the base of
and neck (6,000 cGy), with subsequent place- tongue. The patient was initially treated with
ment of interstitial 1251 implants to the floor of lz5I implants and external-beam radiotherapy
mouth. Six months postimplantation, the patient totaling 5,200 cGy. The patient also received hy-
developed a 3-mm area of exposed mandible on droxyurea and megace chemotherapy. One year
the left side, with biopsies negative for recurrent after her initial treatment, the patient presented
carcinoma. Osteoradionecrosis was diagnosed with left-sided facial and jaw pain and was found
and the patient underwent hyperbaric oxygen to have a friable area on her left lower alveolar
treatment with subsequent debridement and lo- ridge. A Dentascan was obtained and demon-
cal advancement flaps. strated a large lytic lesion in the posterior aspect
Postoperatively, the patient had persistently of the alveolar ridge on the left side (Figure 5A).
exposed mandible. At this time, a Dentascan was Oblique sagittal images revealed erosion of both
obtained which demonstrated loss of the normal the lingual and buccal cortices (Figure 5B).The
dense cortical bone of the left mandible. The ob- patient refused palliative surgery or implanta-
lique sagittal view demonstrated greater involve- tion and died 6 months later after developing
ment of the lingual cortical margin (Figure 4). pulmonary metastases.

FIGURE 4. (A) Axial CT image of the mandible from case 1 using Dentascan.
The area of cortical erosion on the left side is due to osteoradionecrosis. Ra-
diotherapy implants have been placed (arrow). (B)The oblique sagittal view
shows predominantly lingual cortical bone loss (arrow). This information could
not be determined from standard radiographs.

DentaScan Imaging HEAD & NECK JanuaryiFebruary 1993 3

 FIGURE 5. (A) Axial CT image of the mandible from case 2 demonstrating a
stage 4 squamous cell carcinoma of the left tonail with involvement of the left
alveolar ridge. (B)The oblique sagittal CT images reveal erosion of both lin-
gual and buccal mandibular cortical walls.

Case 3. A 26-year-old man with a history of fracture, the patient underwent a Dentascan,
manic depression was initially seen in the emer- which showed an expansile cystic lesion of the
gency room 4 weeks after an assault complaining left mandibular ramus with bony margins
of persistent jaw swelling and pain. The patient thinned but intact. The alveolar canal was
was febrile and had swelling of his right mandibu- pushed near the inferior aspect of the mandible
lar angle and submental area. Intraoral examina- (Figure 8 ) . Through an intraoral approach, the
tion revealed an oral aperture of 30 mm and a patient underwent excision of this large kerato-
right parasymphyseal fracture extending through cyst with preservation of the inferior alveolar
the alveolar ridge with a missing right lateral in- nerve and both buccal and lingual cortices.
cisor. Incision and drainage of the submental area
yielded 20 mL of purulent material that grew Case 5. A 50-year-old woman underwent ex-
mixed flora. Dentascan revealed an oblique right traction of a maxillary molar tooth approxi-
parasymphyseal fracture with malunion. Oblique mately 2 weeks prior to developing fever, puru-
sagittal images demonstrated lingual displace- lent nasal drainage, and maxillary tenderness on
ment of the fracture (Figure 6). The Dentascan the side of the extraction. Physical examination
permitted precise millimeter measurements of revealed a dry socket in hler maxilla. Plain sinus
the bone loss and the fracture, thus assisting in films were obtained and confirmed the diagnosis
preoperative planning. After 1 week of intrave- of acute maxillary sinusitis. The patient’s symp-
nous antibiotics, the patient underwent debride- toms resolved on antibiotic therapy, but redevel-
ment of the parasymphyseal mandible malunion oped soon after completing a 2-week course of
with plate osteosynthesis and iliac crest cancel- antibiotics. Although a persistent dental source
lous bone graft. of infection was suspected\, no mucosal or alveo-
lar ridge abnormality could be seen or probed. A
Case 4. A 22-year-old man was involved in an panorex film was unremarkable and conven-
altercation in which he sustained a trimalar tional CT scan demonstrated maxillary sinusitis,
fracture. Routine facial films revealed a large but no defect in the maxilla (Figure 9).
cystic lesion of the left mandible in addition to A Dentascan was obtaiined and clearly dem-
the fracture (Figure 7). One month after open re- onstrated an oro-antral fistula on both pan-
duction and internal fixation of the trimalar oramic and oblique sagittal views (Figure 10).

4 DentaScan Imaging HEAD & NECK JanuaryiFebruary 1993

 FIGURE 6. (A) Axial CT image of the mandible in case 3 using DentaScan dem-
onstrating parasymphyseal fracture. Note the inferior alveolar canal (arrowhead)
and the mental foramen (arrow). (B)The oblique sagittal images demonstrate lin-
gual displacement of the fracture fragment.

Using these images, the patient underwent sur- tal implants, has proven to be useful in the eval-
gery, and the osseous defect was easily exposed. uation of maxillary and mandibular pathology.
The repair was completed using hydroxylapatite In dentistry and oral surgery, Dentascan has
implant and palatal mucoperiosteal flaps. The been useful in preoperatively identifying pa-
patient remains asymptomatic without any sub- tients with inadequate bone for implantation, as
sequent episodes of sinusitis. well as identifying implant sites in patients who
appeared to be nonimplantible because of insuffi-
DISCUSSION cient bone based on standard radiographs.
Dentascan, though originally designed for the In head and neck surgery, Dentascan is a
preoperative assessment of osseointegrated den- valuable tool in determining the extent of dis-
ease, in particular, the presence of mandibular
invasion. Generally, radiotherapy can be used if
there is no bone involvement, whereas involve-
ment of the mandible (which occurs in 19%-26%
of oral cavity carcinoma^^-^') usually requires
mandibular resection. Using Dentascan, not
only can mandibular involvement be detected,
but mapping of the lesion can be accurately ac-
complished. Buccal and lingual cortical involve-
ment is clearly visualized using the oblique sag-
ittal view. These views permit better operative
planning with regard to the extent of resection
(rim vs segmental mandibulectomy), and the re-
constructive requirements. With this informa-
tion, improved preoperative patient counseling
can be offered.
The available methods for imaging the man-
FIGURE 7. Plain facial x-ray film from case 4 revealed a large
dible which have been previously described in-
cystic lesion (arrow) in the left mandible in addition to a known clude plain x-rays, panorex, bone scan, CT, and
fracture. MRI. Plain films and panorex have been shown

Dentascan Imaging HEAD & NECK January/February 1993 5

FIGURE 8. (A) Axial CT image of the mandible by DentaScan (case 4) showing the left mandibular cystic lesion (arrow). (B) The ob-
lique sagittal CT scan shows inferior displacement of the inferior alveolar canal (arrow). Note that the bony margins of the mandible are
thinned but intact throughout.

to be less sensitive than other modalities.12*13 Bone scans have been a sensitive method for
There is distortion and imprecise detail because detecting mandibular involvement.1i12 These
of the superimposition of various structures. scans, however, have high false-positive rates of
Also, Edelstyn et al. demonstrated that for a de- 53%.1°This lack of specificity results from scans
fect to be visualized on standard x-rays, 75% of which are positive due to inflammatory lesions,
bone thickness in cancellous bone must be ab- infectious processes, and mandibular fractures,
sent.14 Cortical bony defects are more readily de- as well as neoplastic lesions.
tected, especially if viewed in a tangential plane. CT scans are an effective method for the ex-
amination of soft tissues, osseous structures, and
the evaluation of mandibular invasion. Close et
al. described a prospective study of 43 patients
with T2 or greater oral cavity and oropharynx
squamous cell carcinomas, and found 11 cases of
mandibular invasion, all of which were detected
by preoperative CT scans.1°
MRI has been described by Ator et al. as a

FIGURE 9. Standard coronal CT scan from case 5 which dem- FIGURE 10. A DentaScan was obtained (case 5), and a maxil-
onstrates unilateral maxillary sinusitis. No defect in the maxilla lary defect (arrow) could be easily seen on the panoramic view.
could be detected. This represented an oro-antral fistula.

6 Dentascan Imaging HEAD & NECK January/February 1993

useful modality for evaluating the degree of 2. Ator GA, Abemayor E, Lufiin RB, Hanafee WN, Ward
mandibular invasion.2 Bone marrow is well visu- PH. Evaluation of mandibular tumor invasion with mag-
netic resonance imaging. Arch Otolaryngol Head Neck
alized as high signal, but osseous structures are Surg 1990;116:454-459.
only seen indirectly as signal void-black images. 3. Yanagisawa K, Abrahams J J , Friedman CD. DentaScan:
The differentiation of benign and malignant le- a new imaging method for the maxilla and mandible.
Presented at the New England Otolaryngological Soci-
sions can sometimes be made based on the ap- ety, Boston, MA, October 1990.
pearances on "1- and T2-weighted images. 4. Vining E, Friedman CD, Abrahams J J , Lowlicht R. Di-
DentaScan also has great utility in the evalu- agnosis of oroantral fistula using DentaScan. Poster pre-
sentation a t the American Academy of Otolaryngology-
ation of trauma to the facial skeleton. The ob- Head and Neck Surgery, San Diego, CA, September
lique sagittal view offers additional information 1990.
about the degree and extent of displacement in 5 . Abrahams J J , Levine B. Expanded applications of Den-
taScan (multiplanar computerized tomography of the
anteroposterior, vertical, and horizontal orienta- mandible and maxilla). Int J Periodont Rest Dent
tions. With this information, the operative ap- 1990;10:465-471.
proach, the requirements for repair including the 6. Schwarz MS, Rothman SLG, Chafetz N, Rhodes M. Com-
puted tomography in dental implantation surgery. Dent
need for bone grafts, the selection and preopera- Clin North A m 1989;33:555-597.
tive bending and modeling of appropriate recon- 7. Schwarz MS,Rothman SLG, Rhodes M, Chafetz N. Com-
struction plates, the measurement of necessary puted tomography: part I. Preoperative assessment of the
mandible for endosseous implant surgery. Int J Oral
screw lengths, and the use of mandibular lag Maxillofac Implants 1987;2:137- 141.
screw osteosynthesis can all be planned preoper- 8. Schwarz MS, Rothman SLG, Rhodes ML, Chafetz N.
atively, thus reducing intraoperative time. Computed tomography: part 11. Preoperative assessment
of the maxilla for endosseous implant surgery. Int J Oral
DentaScan computer software program is Maxillofac Implants 1987;2:143- 148.
readily available and provides valuable informa- 9. Marchetta FC, Sako K, Murphy JB. The periosteum of
tion about the mandible and maxilla. The unique the mandible and intraoral carcinoma. Am J Surg - 1971;
122:711-713.
oblique sagittal view, the ability to visualize in- 10. Close LG, Merkel M, Burns DK, Schaefer SD. Computed
ternal structures, and the capacity for precise tomography in the assessment of mandibular invasion by
millimeter measurements make this modality intraoral carcinoma. A n n Otol Rhino1 Laryngol 1986;
95:383-388.
superior to other available imaging techniques. 11. Gilbert S,Tzadik A, Leonard G. Mandibular involvement
In our experience, it has been useful in the eval- by oral squamous cell carcinoma. Laryngoscope 1986;
uation of head and neck neoplasms, infectious - - G.- - -7 ni.
CWI .- .
12. Baker HL, Woodbury DH, Krause CJ, Saxon KG, Stew-
diseases, osteoradionecrosis, and accurate assess- art RC. Evaluation of bone scan by scintigraphy to detect
ment in trauma cases. As further experience is subclinical invasion of the mandible by squamous cell
gained using this technique, additional applica- carcinoma of the oral cavity. Otolaryngol Head Neck
Surg 1982;90:327-336.
tions may be found. 13. Weisman RA, Kimmelman CP. Bone scanning in the as-
sessment of mandibular invasion by oral cavity carcino-
mas. Laryngoscope 1982;92:1-4.
14. Edelstyn GA, Gillespie PJ, Grebbell FS. The radiological
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DentaScan Imaging HEAD & NECK January/February 1993 7