DENTASCAN IMAGING OF THE MANDIBLE
AND MAXILLA
Ken Yanagisawa, MD, Craig D. Friedman, MD, Eugenia M. Vining, MD,
and James J. Abrahams, MD
DentaScan is a unique new computer software program which
provides computed tomographic (CT) imaging of the mandible
and maxilla in three planes of reference: axial, panoramic, and
oblique sagittal (or cross-sectional). The clarity and identical
scale between the various views permits uniformity of measure-
ments and cross-referencing of anatomic structures through all
three planes. Unlike previous imaging techniques, the oblique
sagittal view permits the evaluation of distinct buccal and lingual
cortical bone margins, as well as clear visualization of internal
structures, such as the incisive and inferior alveolar canals. Sev-
eral case reports are presented to demonstrate the clinical use-
fulness of Dentascan.
HEAD AND NECK 1993;15:1-7
0 1993 John Wiley & Sons, Inc.
It has been previously difficult to precisely de-
termine the degree of disease or injury to the
mandible and maxilla using diagnostic imaging
techniques. In the case of oral cavity and oropha-
ryngeal carcinoma, the presence and degree of
mandibular invasion has a great impact on
treatment planning. Thus, accurate preoperative
assessment of the mandible is essential.
Methods of imaging the mandible and max-
From the Section of Otolaryngology-Head and Neck Surgery, and the
Section of Neuroradiology, Department of Diagnostic Radiology. Yale
University School of Medicine, New Haven, Connecticut.
Address reprint requests to Dr. Friedman at the Section of Otolaryngol-
ogy. Department of Surgery, Yale University School of Medicine, Box
3333, 333 Cedar Street, New Haven, CT 06510.
Accepted for publication April 28. 1992
CCC 0148-6403/93/0101-07
0 1993 John Wiley & Sons, Inc
Dentascan Imaging
illa have included plain x-rays, tomograms, pan-
oramic radiography (panorex), computed tomo-
graphic (CT) scans, and, more recently, bone
scans,' magnetic resonance imaging (MRI)
scans,' and three-dimensional reconstruction CT
scans. Each of these modalities has shortcomings
that limit their clinical utility.
Dentascan is a CT computer software pro-
gram that produces multiple cross-referenced im-
ages of the jaw in the axial, cross-sectional, and
panoramic views. Introduced in the mid-l980s, it
offers several significant improvements in the
evaluation of the osseous mandible and maxilla
and has been reported to be useful in head and
neck ~ u r g e r y . ~Through
-~ a series of case re-
ports, we more clearly define the application and
use of DentaScan in head and neck surgery.
MATERIALS AND METHODS
Between January 1990 and June 1991, 30 pa-
tients at Yale-New Haven Hospital (New Ha-
ven, CT) were selected in a nonconsecutive fash-
ion for this study. All had obvious or suggested
pathology involving the mandible and maxilla.
There were 15 cases of head and neck carcinoma,
eight cases of facial/mandibular trauma, and
seven cases of benign lesions, including amelo-
blastoma, keratocyst, oroantral fistula, osteora-
dionecrosis, and hemangioma. All patients had
pathologic confirmation of diagnosis based on the
surgical specimen or biopsy.
CT scans were obtained using dynamic scan-
ning mode on GE 9800 scanners with a 2-second
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-
pendicular to this curve define the oblique sagittal images.
scan time, 140 kV peak, and 70 mA. One-
millimeter axial sections were made of the man-
dible. Axial sections of 1.5 mm were made of the
maxilla. Using the Dentascan computer soft-
ware program (General Electric Medical System,
Milwaukee, WI), images were reformatted into
panoramic and oblique sagittal views based on
the axial scans.
DentaScan permits visualization of the man-
dible and maxilla in three planes: axial, pan-
oramic, and oblique sagittal (cross-sectional)
(Figures 1-3). Axial CT scans are obtained in
the usual fashion a t intervals of 1.0 mm for the
mandible, and 1.5 mm for the maxilla. An aver-
age mandibular scan requires 30-35 sections; a n
average maxillary scan, 20-30 sections. The
computer program uses the data from the axial
images to reformat new images in the panoramic
and oblique sagittal planes. Cross-referencing
anatomic structures in all three planes is easily
accomplished through a series of marks on the
FIGURE 2. Panoramic Dentascan image of the mandible. Note
the inferior alveolar canal (arrow).
2 DentaScan Imaging
FIGURE 3. Oblique sagittal CT image of the mandible using
Dentascan. Note the mental foramen in cross-section in frame
no. 25 (arrow).
side and botton of each image, and a millimeter
scale which allows accurate measurements."-A
The axial views are obtained in 1.0- to
1.5-mm intervals (Figure 1). Using one of these
images, the CT technologist then places a series
of points along the curve of the mandible or max-
illa using the cursor on the scanner console. The
computer joins these points to produce a smooth
curve, which is superimposed on the image of the
jaw. This line then defines the plane and location
for reformatting the panoramic images. A series
of lines perpendicular to this curve are then cre-
ated by the computer a t intervals (usually 2 mm)
to define the plane and location of the cross-
sectional (oblique sagittal) images. These lines
are numbered from right to left, allowing for
easy identification of the corresponding num-
bered images.
Unlike the standard panorex film, the Den-
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-
tures, such as the inferior alveolar canal, the
mental foramen, the mandibular foramen, the ge-
HEAD K NECK JanuaryiFebruary 1993
nial tubercle, the greater and lesser palatine fora-
men, the incisive canal, and the maxillary sinus.
The marks along the side border again represent
the location of each axial image. The five marks
along the bottom border of each frame depict
the location of each panoramic image.
CASEREPORTS
Case 1. A 60-year-old man with a history of ex-
tensive alcohol and tobacco use presented with a
TlNlMO stage 111 squamous cell carcinoma of
the floor of mouth. The patient was treated with
excisional biopsy of a neck node and external-
beam radiotherapy to the oral cavity (5,400 cGy)
and neck (6,000 cGy), with subsequent place-
ment of interstitial 1251 implants to the floor of
mouth. Six months postimplantation, the patient
developed a 3-mm area of exposed mandible on
the left side, with biopsies negative for recurrent
carcinoma. Osteoradionecrosis was diagnosed
and the patient underwent hyperbaric oxygen
treatment with subsequent debridement and lo-
cal advancement flaps.
Postoperatively, the patient had persistently
exposed mandible. At this time, a Dentascan was
obtained which demonstrated loss of the normal
dense cortical bone of the left mandible. The ob-
lique sagittal view demonstrated greater involve-
ment of the lingual cortical margin (Figure 4).
Differentiation between buccal and lingual in-
volvement was not possible with the other imag-
ing modalities. A rim mandibulectomy with pec-
toralis major myocutaneous flap reconstruction
was carried out. Of note, permanent sections of
the floor of mouth specimen revealed carcinoma in
situ and superficially invasive squamous cell car-
cinoma with clear margins. The patient did well
postoperatively without subsequent soft tissue
breakdown.
Case 2. A 62-year-old woman was initially seen
with a T4N2MO stage IV squamous cell carci-
noma of the left tonsil extending to the base of
tongue. The patient was initially treated with
lz5I implants and external-beam radiotherapy
totaling 5,200 cGy. The patient also received hy-
droxyurea and megace chemotherapy. One year
after her initial treatment, the patient presented
with left-sided facial and jaw pain and was found
to have a friable area on her left lower alveolar
ridge. A Dentascan was obtained and demon-
strated a large lytic lesion in the posterior aspect
of the alveolar ridge on the left side (Figure 5A).
Oblique sagittal images revealed erosion of both
the lingual and buccal cortices (Figure 5B).The
patient refused palliative surgery or implanta-
tion and died 6 months later after developing
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
manic depression was initially seen in the emer-
gency room 4 weeks after an assault complaining
of persistent jaw swelling and pain. The patient
was febrile and had swelling of his right mandibu-
lar angle and submental area. Intraoral examina-
tion revealed an oral aperture of 30 mm and a
right parasymphyseal fracture extending through
the alveolar ridge with a missing right lateral in-
cisor. Incision and drainage of the submental area
yielded 20 mL of purulent material that grew
mixed flora. Dentascan revealed an oblique right
parasymphyseal fracture with malunion. Oblique
sagittal images demonstrated lingual displace-
ment of the fracture (Figure 6). The Dentascan
permitted precise millimeter measurements of
the bone loss and the fracture, thus assisting in
preoperative planning. After 1 week of intrave-
nous antibiotics, the patient underwent debride-
ment of the parasymphyseal mandible malunion
with plate osteosynthesis and iliac crest cancel-
lous bone graft.
Case 4. A 22-year-old man was involved in an
altercation in which he sustained a trimalar
fracture. Routine facial films revealed a large
cystic lesion of the left mandible in addition to
the fracture (Figure 7). One month after open re-
duction and internal fixation of the trimalar
fracture, the patient underwent a Dentascan,
which showed an expansile cystic lesion of the
left mandibular ramus with bony margins
thinned but intact. The alveolar canal was
pushed near the inferior aspect of the mandible
(Figure 8 ) . Through an intraoral approach, the
patient underwent excision of this large kerato-
cyst with preservation of the inferior alveolar
nerve and both buccal and lingual cortices.
Case 5. A 50-year-old woman underwent ex-
traction of a maxillary molar tooth approxi-
mately 2 weeks prior to developing fever, puru-
lent nasal drainage, and maxillary tenderness on
the side of the extraction. Physical examination
revealed a dry socket in hler maxilla. Plain sinus
films were obtained and confirmed the diagnosis
of acute maxillary sinusitis. The patient’s symp-
toms resolved on antibiotic therapy, but redevel-
oped soon after completing a 2-week course of
antibiotics. Although a persistent dental source
of infection was suspected\, no mucosal or alveo-
lar ridge abnormality could be seen or probed. A
panorex film was unremarkable and conven-
tional CT scan demonstrated maxillary sinusitis,
but no defect in the maxilla (Figure 9).
A Dentascan was obtaiined and clearly dem-
onstrated an oro-antral fistula on both pan-
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-
gery, and the osseous defect was easily exposed.
The repair was completed using hydroxylapatite
implant and palatal mucoperiosteal flaps. The
patient remains asymptomatic without any sub-
sequent episodes of sinusitis.
DISCUSSION
Dentascan, though originally designed for the
preoperative assessment of osseointegrated den-
FIGURE 7. Plain facial x-ray film from case 4 revealed a large
cystic lesion (arrow) in the left mandible in addition to a known
fracture.
tal implants, has proven to be useful in the eval-
uation of maxillary and mandibular pathology.
In dentistry and oral surgery, Dentascan has
been useful in preoperatively identifying pa-
tients with inadequate bone for implantation, as
well as identifying implant sites in patients who
appeared to be nonimplantible because of insuffi-
cient bone based on standard radiographs.
In head and neck surgery, Dentascan is a
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-
dible which have been previously described in-
clude plain x-rays, panorex, bone scan, CT, and
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
There is distortion and imprecise detail because
of the superimposition of various structures.
Also, Edelstyn et al. demonstrated that for a de-
fect to be visualized on standard x-rays, 75% of
bone thickness in cancellous bone must be ab-
sent.14 Cortical bony defects are more readily de-
tected, especially if viewed in a tangential plane.
FIGURE 9. Standard coronal CT scan from case 5 which dem-
onstrates unilateral maxillary sinusitis. No defect in the maxilla
could be detected.
6 Dentascan Imaging
Bone scans have been a sensitive method for
detecting mandibular involvement.1i12 These
scans, however, have high false-positive rates of
53%.1°This lack of specificity results from scans
which are positive due to inflammatory lesions,
infectious processes, and mandibular fractures,
as well as neoplastic lesions.
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 10. A DentaScan was obtained (case 5), and a maxil-
lary defect (arrow) could be easily seen on the panoramic view.
This represented an oro-antral fistula.
HEAD & NECK January/February 1993
useful modality for evaluating the degree of
mandibular invasion.2 Bone marrow is well visu-
alized as high signal, but osseous structures are
only seen indirectly as signal void-black images.
The differentiation of benign and malignant le-
sions can sometimes be made based on the ap-
pearances on "1- and T2-weighted images.
DentaScan also has great utility in the evalu-
ation of trauma to the facial skeleton. The ob-
lique sagittal view offers additional information
about the degree and extent of displacement in
anteroposterior, vertical, and horizontal orienta-
tions. With this information, the operative ap-
proach, the requirements for repair including the
need for bone grafts, the selection and preopera-
tive bending and modeling of appropriate recon-
struction plates, the measurement of necessary
screw lengths, and the use of mandibular lag
screw osteosynthesis can all be planned preoper-
atively, thus reducing intraoperative time.
DentaScan computer software program is
readily available and provides valuable informa-
tion about the mandible and maxilla. The unique
oblique sagittal view, the ability to visualize in-
ternal structures, and the capacity for precise
millimeter measurements make this modality
superior to other available imaging techniques.
In our experience, it has been useful in the eval-
uation of head and neck neoplasms, infectious
diseases, osteoradionecrosis, and accurate assess-
ment in trauma cases. As further experience is
gained using this technique, additional applica-
tions may be found.
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DentaScan Imaging
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HEAD & NECK January/February 1993 7