ORIGINAL RESEARCH

Utility of Transfacial Dental

Ultrasonography in Evaluation
of Cystic Jaw Lesions
Khaled Gad, MD, MHPE , Mohamed Ellabban, MD, James Sciubba, DMD, PhD

Objectives—Plain radiography has been widely used in dentistry. Because of the var-
iability of the quality of equipment, radiographic technique, accuracy of interpreta-
tion, and radiation risk to the patients, the field is ripe for the introduction of other
newer diagnostic modalities. In this report, we demonstrate the utility of ultrasonog-
raphy in the diagnostic workup of cystic or cystlike lesions of the jaw.
Methods—We used a transfacial ultrasonographic scanning approach to examine 32
patients with clinical or radiographic presentation of a jaw cyst. Computed tomogra-
phy and histopathologic analysis were used as the reference standards to confirm
the findings.
Results—Ultrasonography could establish the presence or absence of a lesion, ero-
sion of the buccal cortical plate, and identification of associated soft tissue involve-
ment in all cases (sensitivity and specificity, 100% and 100%, respectively; area
under the receiver operating characteristic curve, 1.0; P < .001).
Conclusions—Our observations revealed the usefulness of ultrasonography and
demonstrated its potential value when introduced as a routine office-based imaging
method for dentistry.
Key Words—dental computed tomography; head and neck; jaw cysts;
transfacial dental ultrasonography

R
adiography is extensively used in the field of dentistry as well
Received May 15, 2017, from the Department as maxillofacial surgery. Panoramic radiography and periapical
of Radiology (K.G.) and Division of Plastic and films are considered the backbones of diagnostic oral imaging
Reconstructive Surgery (M.E.), Suez Canal studies. Digital panoramic radiography was introduced to the clinical
University School of Medicine, Ismailia, Egypt; setting after being approved by the US Food and Drug Administra-
Department of Head and Neck Surgery,
Johns Hopkins University School of Medicine, tion more than 2 decades ago, with enhanced diagnostic performance
Baltimore, Maryland USA (J.S.); and Milton J. and a decreased radiation dose.1
Dance Head and Neck Center, Greater Balti- One of the limitations of panoramic radiography, whether con-
more Medical Center, Baltimore, Maryland ventional or digital, is the nonvisualization of the buccolingual plane.
USA (J.S.). Manuscript accepted for
publication June 6, 2017. Radiographs are 2-dimensional images that may distort the actual
Address correspondence to Khaled Gad, lesion size and detectability.2 Radiography also has limited spatial
MD, MHPE, Department of Radiology, Suez resolution, which may challenge the perception of the lesion location
Canal University School of Medicine, Ring and depth relative to adjacent structures such as teeth and neurovas-
Road, Ismailia, Egypt.
cular canals.3 Other limitations of panoramic radiography include the
E-mail: khaled_gad@med.suez.edu.eg
following: (1) failure to detect osteolytic lesions if bone loss is less
Abbreviations than 12.5% and 6.6% in cortical bone and mineralized bone, respec-
CT, computed tomography; US, tively4; (2) inability to visualize soft tissue abnormalities related to
ultrasonography bony lesions; and (3) frequently encountered artifacts, which may
result in lesion distortion, particularly near the midline.5
doi:10.1002/jum.14374

C 2017 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2017; 00:00–00 | 0278-4297 | www.aium.org
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Gad et al—Transfacial Dental Ultrasonography of Cystic Jaw Lesions

Radiation exposure is an additional consideration The application of diagnostic real-time US in dentistry

with use of panoramic radiography. The effective dose has been explored in recent published studies.12–17 A
has been calculated in the range of 14 to 24 lSv.6 The high-resolution transducer is typically used either intraor-
radiation risk is relatively low but must be considered for ally over the gingival mucosa or extraorally over the skin.
the nearby radiosensitive organs, such as the thyroid, sal- When compared to conventional radiography, US has
ivary glands, lens, and brain.7–10 proven to be a valuable technique that shows a greater
Limitations of panoramic radiography have been ability to differentiate cystic from noncystic jaw lesions.18
largely overridden with the advent of dental computed It is effective in evaluations of periapical lesions, with
tomography (CT), which was introduced in 1987. higher sensitivity and specificity compared to conven-
With the aid of dental processing software, it was possi- tional or digital radiography.19 Furthermore, it showed
ble to reconstruct axial CT images into panoramic and greater accuracy concerning the pathologic nature of
para-axial reformats with a revolutionary change in the lesions.20 Ultrasonography with color/power Doppler
science of oral/dental imaging by that time. In 2001, imaging of periapical lesions can provide specific infor-
cone beam CT scanners were approved by the Food mation on the size of the lesion, its vascular supply, and
and Drug Administration in the United States and pre- internal content, with the ability to distinguish clear from
sented a new and dedicated CT imaging system to the mixed fluid, mucus, or purulent content.21 A periapical
field of dentistry. It gives a cone-shaped beam instead cyst can be distinguished from a granuloma.22 Ultraso-
of the fan-shaped beam used with conventional CT nography has also been found to be an efficient tool in
scanners. A focused field of view could be flexibly tai- monitoring bone healing after treatment of periapical
lored to the patient’s clinical presentation, resulting in lesions.23,24 Moreover, it can clearly show a high-
higher-resolution images and a lower radiation dose resolution 2-dimensional contour of the dentoenamel
compared to conventional CT.11 Computed tomogra- junction.25,26 In this report, we aim at highlighting the
phy is widely used in evaluations of jaw lesions. Bone utility of US in evaluation of jaw cysts.
and soft tissue characterization is clear without superim-
position of anatomic structures. Limitations of typical Materials and Methods
CT include limited availability or experience in inter-
pretation, higher cost, and radiation exposure (which On approval by the Institutional Review Board, 32
can be minimized with cone beam CT), but the total patients were included in our study after being referred
radiation dose is still higher than that of conventional to our imaging facility with a suspected diagnosis of a
radiographic examinations. cystic lesion of the jaw according to panoramic radiogra-
Ultrasonography (US) is a noninvasive, painless, phy, a clinical examination, or both. Patients were exam-
radiation-free, and low-cost imaging modality that is ined by an expert radiologist who was blinded to
being extensively used in different fields of medicine. panoramic radiographic or CT results. An extraoral

Figure 1. Technique of transfacial dental US showing transducer positions in transverse posterior left lower (A), vertical anterior right upper (B),
and vertical oblique left lower (C) scanning planes.

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 Gad et al—Transfacial Dental Ultrasonography of Cystic Jaw Lesions

linear US transducer (7–12 MHz) with a LOGIQ E5 characteristic curves were generated and used to test
US system (GE Healthcare, Milwaukee, WI) was used the significance of the results.
and applied over the skin of the patient’s face at the site
of the suspected lesion. Vertical, horizontal, oblique, or
Results
free planes were scanned (Figure 1). Lubricating gel was
used over the skin as an acoustic medium. Oral saliva
The 32 study participants included 19 male and 13
represented a naturally occurring internal acoustic
female patients (mean age 6 SD, 32.9 6 18.2 years).
medium; however, some patients were encouraged to
Twenty-eight inflammatory and neoplastic lesions were
take a bolus of water and hold it inside the mouth
included, as well as 4 patients who turned out to have
between the lips/cheek and teeth to act as an internal
normal findings (Table 1). Among the 28 true cases,
acoustic medium, which enhanced US beam transmis-
sion from the skin into the dental or bony structures of lesion sizes ranged from 0.019 to 40.856 cm3 with a
the mandible or maxilla. Color/power Doppler mapping median of 0.622 cm3 (95% confidence interval, 0.304–
as well as a pulsed wave Doppler flow display supple- 3.460 cm3). Most lesions (71%) were smaller than 5 cm3
mented all studies. (Figure 2).
All referred patients had panoramic radiography Transfacial dental US performed outstandingly,
before the US examination, then CT was done to all recording 100% sensitivity and specificity in establishing
of them to serve as the reference standard. Panoramic the presence of a true lesion (28 of 28 true-positive cases
radiography and CT were interpreted by an oral radiol- and 4 of 4 true-negative negative cases), detecting ero-
ogist. We designated our US examination technique sion of the buccal cortical plate (19 of 19 true-positive
“transfacial dental US.” The final diagnosis was estab- cases and 13 of 13 true-negative cases), and identifying
lished by excision histopathologic analysis or clinical associated soft tissue involvement (9 of 9 true-positive
assessment in 21 and 11 cases respectively. The 11 (clin- cases and 23 of 23 true-negative cases), whether it was
ically judged) patients included 7 patients with periapical edema or infiltration (area under the receiver operating
granulomas who received medical treatment and 4 characteristic curve, 1.0; P < .001).
patients who turned out to be lesion free. Transfacial dental US enabled the radiologist to
Statistical analysis was performed with MedCalc detect all 6 cases with an unerupted tooth located inside
version 16.4.3 software for windows (MedCalc Soft- the lesion; however, it falsely interpreted an echogenic
ware, Mariakerke, Belgium). Sensitivity and Specificity shadow as a tooth structure in 1 case, only recording
values for transfacial dental US were estimated com- sensitivity and specificity of 100% and 96.2%, respec-
pared to CT (reference standard). Receiver operating tively (Figure 3).
Erosion of the lingual/palatal cortical plate was
detected by transfacial dental US in 3 of 4 true cases,
Figure 2. Lesion distribution according to volume, with most (71%) whereas it was falsely overrated in 2 of 25 cases without
of the lesions smaller than 5 cm3 in volume.
true erosion on CT, reaching sensitivity and specificity
of 42.9% of 92%. We could not establish statistical signif-
icance with the receiver operating characteristic analysis.

Table 1. Frequency of Lesions According to Their Final

Diagnosis
Diagnosis Cases
Periapical granuloma 10
Radicular cyst 5
Odontogenic keratocystic tumor 5
Dentigerous cyst 3
Giant cell lesion 3
Osteomyelitis 2
No cyst 4
Total 32

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Gad et al—Transfacial Dental Ultrasonography of Cystic Jaw Lesions

Establishing the effect of the lesion on an adjacent On the other hand, US could identify a paradental
neurovascular canal either due to displacement or ero- cyst that was missed on panoramic radiography, where
sion through its wall was possible by transfacial dental the buccal plate was resorbed but the lingual cortex was
US in 6 of 9 positive cases and was falsely overrated in 1 intact (Figure 5), a factor that made it impossible for
of 23 negative cases, reaching sensitivity and specificity panoramic radiography to visualize the lesion. This find-
of 66.7% and 95.7% (Figure 4). ing was supported by Bender and Seltzer27 in their study
of 558 artificial lesions made with different grades of
Discussion cortical perforation into mandibles of human cadavers.
The authors concluded that lesions are distinguishable
In this study, we tried to explore and highlight the clini- on roentgenograms only when there is sufficient destruc-
cal utility of transfacial dental US in evaluation of jaw tion of the cortical plates or their innermost surfaces
cystic lesions. Although US is known to be an operator- because cortical bone contains more calcium per unit
dependent diagnostic modality that requires training and volume than cancellous bone. Patel et al28 further inves-
practice, we believe that no specialized or advanced tigated this idea in another study on periapical lesions, in
training is needed to perform transfacial dental US other which they explained the poor detection of some lesions
than those basic skills for performing a standard scan. A by the “anatomical noise” induced by a thick, intact cort-
learning curve is expected to progress with doing more ical plate. In our study, US was found to be useful in
cases, but the bottom line is that transfacial dental US assessing the buccal cortical plate, which is close to the
seems to be a simple technique that applies the same transducer, making it superior to panoramic radiography
concept and scanning protocol of any superficial US in a setting in which bone destruction is minimal if any
examination. We could functionalize the diagnostic role at the lingual plate, creating anatomic noise that masked
of transfacial dental US in different clinical settings. Add- lesion visibility on radiography.
ing this relatively unused imaging modality was helpful Ultrasonography is generally able to differentiate
in aiding the diagnosis by means of the following cystic from solid lesions because of its accurate charac-
features: terization of fluid, which is typically anechoic (dark) and
may contain internal echoes or have posterior acoustic
Lesion Characterization enhancement.16 Cystic lesions of the upper jaw near the
It was possible to visualize all cystic lesions clearly by base of maxillary sinuses can sometimes represent a diag-
US. Moreover, the role of transfacial dental US as nostic challenge on panoramic radiography because of
a problem solver could also be explored in some variable extension and pneumatization patterns of maxil-
cases. False-positive lesions on panoramic radiography, lary sinuses, which can give illusive impressions of tooth
whether due to artifacts or osteopenia within medullary roots projecting into the sinuses.29 Extensive pneumati-
expansion adjacent to an impacted tooth, were correctly zation of maxillary sinuses was reported in one study in
ruled out by US.
Figure 4. Receiver operating characteristic analysis of the
Figure 3. Receiver operating characteristic analysis of the performance of transfacial dental US (compared to CT) to establish
performance of transfacial dental US (compared to CT) to identify the effect of the lesion on an adjacent neurovascular canal (NVC) due
teeth or dental structures inside the lesion. AUC indicates area under to either displacement or erosion. AUC indicates area under the
the curve. curve.

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 Gad et al—Transfacial Dental Ultrasonography of Cystic Jaw Lesions

8% of the population.30 Aberrant anatomy of the maxil- and appears bright on US, whereas fluid (in the cyst)
lary sinus base can even mimic a cyst.31,32 The odonto- appears as a hypoechoic structure. Even with some tur-
genic keratocystic tumor case (Figure 6) was a good bidity inside a cyst mimicking a solid lesion, it was possi-
example to demonstrate how accurately our US tech- ble to suggest its fluid nature because of the posterior
nique was able to detect a cystic lesion adjacent to the acoustic enhancement, as seen in the case of a dentiger-
maxillary sinus base. Air (in the sinus) is echo reflective ous cyst (Figure 7).

Figure 5. Panoramic radiography (A), transfacial dental US (B), and 3-dimensional CT (C) from a 6-year-old girl who presented with a small palpa-
ble and tender swelling over the left side of the mandibular body. Panoramic radiography (A) was frequently done and showed no abnormality
(arrows). Transfacial dental US (B) rotated 90 8 for better visualization revealed a cavity (cyst) through a bony defect in the buccal cortex (arrow-
heads) with an intact lingual (inner) cortical plate that completely masked the lesion on conventional panoramic radiography. On the US evalua-
tion (B), a lesion was seen extending into the buccal gingival soft tissues. Two hyperechoic linear structures are seen inside a deciduous (arrow)
and underlying erupting (open arrow) molar follicle. Power Doppler imaging showed rich vascularity (due to the intense inflammatory process)
within the lesion. Computed tomography (C) confirmed the presence of the buccal (lateral) cyst, which was diagnosed by pathologic analysis as
an inflammatory paradental (radicular) cyst.

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Gad et al—Transfacial Dental Ultrasonography of Cystic Jaw Lesions

Tooth Visualization junction. Transfacial dental US was able to show an

Teeth appeared as very bright (hyperechoic) structures erupting tooth under a deciduous one. Teeth apices
embedded within a less-echogenic periodontal bone. were also confirmed by the presence of linear vascular
The unerupted tooth in the case of the dentigerous cyst flow due to the location of the dental neurovascular bun-
was clearly seen on US (Figure 7). The crown inside the dle. The spatial relationship between the lesion and teeth
lesion, which was important for diagnosing a dentigerous is very important for differential diagnosis when a cyst is
cyst, was also confirmed by visualizing the dentoenamel being suspected as periapical or not. This question can

Figure 6. Panoramic radiography (A), transfacial dental US (B), and axial CT (C) from a 34-year-old man who presented with a chronic right maxil-
lary swelling and loosening of adjacent teeth. Panoramic radiography (A) showed an osteolytic lesion at the right maxilla expanding through the
maxillary alveolus (arrowheads).Transfacial dental US (B) revealed an expansile cystic lesion with a lobulated outline. No teeth were present within
the radiolucent lesion. A cortical bony defect could be delineated along its anterior labial wall (open arrows in B and C). An intact vascular canal
was seen anteromedial to the lesion, representing the nasopalatine artery (arrows in B and C). Peripheral lobulation as well as the erosive nature
of the lesion suggested rather aggressive behavior. Computed tomography (C) confirmed the previous findings. Pathologic analysis was done
and confirmed the diagnosis of an odontogenic keratocystic tumor.

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 Gad et al—Transfacial Dental Ultrasonography of Cystic Jaw Lesions

sometimes be unanswered on panoramic radiography impedances through different dental parts, it was estab-
because of nonvisualization of the buccolingual plane lished that the water-enamel interface is the highest
(depth of the lesion). Ultrasonography was able to con- sound-reflective layer (very bright), followed by the
firm the periapical location of cysts by detecting teeth enamel-dentin and dentin-pulp interfaces.25,33,34 The
apices or their apical vascular flow inside the lesion, as sound velocity is inversely proportional to the tissue
it was in the case of a posttraumatic radicular cyst density, which impedes sound transmission.33 The den-
(Figure 8). toenamel junction has a tissue interface that can be
Our observations on tooth visualization on US clearly seen on US.33 Laser Doppler flowmetry is a well-
supported other findings in the literature. According to established modality used to assess vascular flow in the
studies on measuring sound velocities and acoustic dental pulp because of the ability of the laser beam to

Figure 7. Three-dimensional CT (A), panoramic radiography (B), and transfacial dental US (C and D) from a 9-year-old child who presented with
a painless swelling at the right side of the mandible. Panoramic radiography (B) showed a cyst with an unerupted tooth. Transfacial dental US (C)
revealed a bony defect (open arrows) through which a hypoechoic rounded cystic cavity was seen with associated posterior acoustic enhance-
ment (arrowheads), compatible with the cystic nature of the lesion. This posterior enhancement was partially interrupted because of the presence
of a linear hyperechoic structure representing an unerupted tooth (arrow in C, matching the arrows in A and B), which was located totally within
the lesion along its inferior extent. Power Doppler imaging (D) showed vascular flow anteriorly at the cyst wall and also near the root apex of the
unerupted tooth, where the neurovascular bundle normally enters the teeth. Computed tomography (A) confirmed the diagnosis of a cystic odon-
togenic lesion, which was diagnosed by histopathologic analysis as a dentigerous cyst.

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Gad et al—Transfacial Dental Ultrasonography of Cystic Jaw Lesions

penetrate hard tissues.35 The use of color/power Dopp- Assessment of Bony Cortical Plates
ler US has been reported in the literature in evaluations Bone expansion is an important feature of slowly grow-
of pathologic lesions and monitoring of treatment.23,24 ing (typically benign) lesions. Transfacial dental US was
In this study, we could introduce another value of color/ able to detect not only bone expansion but also bone
power Doppler US as a routine part of a US scan for vis- resorption where the cortical plate was missing. The
ualization of the vascular bundle (Figure 8) as it enters dentigerous cyst, odontogenic keratocystic tumor, and
the tooth apex, where no impeding hard tissue structures posttraumatic radicular cyst were 3 examples in which
are normally present. the cortical plates showed small areas of focal erosion, an

Figure 8. Panoramic radiography (A), axial CT (B), and transfacial dental US (C) from a 27-year-old man who had mandibular midline cystic radio-
lucency on panoramic radiography (A) in a location periapical to the lower incisors, which had their root apices (black arrows in A and B) at the
level of the upper border of the cystic alteration. Transfacial dental US (C) showed the cystic lesion and revealed focal erosion of the expanded
buccal cortex (open arrows in B and C). It was difficult to identify the location of root apices relative to the cyst; however, the 4 vascular bundles
of the lower incisors (long and short arrows in C) were clearly shown within the cyst, confirming its periapical location. A posttraumatic radicular
cyst was diagnosed, supported by tooth vitality testing as well as a remote history of trauma to the area of the radiographic lesion.

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important finding for understanding the behavior of the 2. Van der Stelt PF. Experimentally produced bone lesions. Oral Surg
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