555

Pictorial
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Essay

Normal and Pathologic CT Anatomy of the Mandible

Anne G. Osbonn,1 William H. Hanafee,2 and Anthony A. Mancuso1

The value of computed tomography (CT) in the diagnosis The superior (alveolar) border supports the teeth (1 6 in a
and management of a wide variety of facial lesions has been normal adult) and is hollowed into variable sized, irregularly
amply demonstrated [1 -3]. While a number of studies have shaped sockets (fig. 1 C). The inferior border of the mandible
focused on CT anatomy of the paranasal sinuses, nose, and is thicker and quite smooth except for a shallow groove
nasophanynx [4-6], none has concentrated on the mandible. where the facial artery crosses it.
Although the mandible is difficult to image because of its Each mandibular ramus has two surfaces, four borders,
complex, curving surfaces and the presence of artifact- and two processes [7]. The medial surface has an ovoid
producing amalgam fillings or restorations, CT of the man- mandibular foramen in its center. The inferior alveolar yes-
dible can nevertheless be highly informative in selected sels and nerve enter this foramen and course antenoinfer-
cases. This pictorial essay depicts normal gross and CT iorly through the mandibular canal to exit at the mental
anatomy of the mandible and presents a series of cases that foramen. Multiple mandibular canals are occasionally iden-
illustrate the utility of CT in examining mandibular lesions. tified [8].
The superior bonder of the ramus presents two processes:
the thin triangular coronoid process anteriorly and the
Normal Gross Anatomy thicken condylar process posteriorly. These two processes
The mandible has two major components: the mandible are separated by the U-shaped mandibular notch. The man-
proper and the alveolus (teeth-bearing part). The mandible dibulan condyle has an oval surface superiorly for anticula-
proper consists of a horizontal segment (the body) and two tion with the anticulan disk of the temponomandibulan joint.
roughly perpendicular parts (the rami) that join the body The articulan condyle is attached to the namus by a thinner
posteriorly at nearly night angles. The external surface of supporting segment, the neck. Viewed from above (fig. 1 C),
the mandible is marked anteriorly by a faint midline ridge, the mandibular condyles do not usually form a night angle
the symphysis menti, and a triangular eminence, the mental with the midsagittal plane of the skull, but lie 5#{176}-30#{176}
from
protuberance (fig. 1 A). The mental fonamina lie in the mid- the coronal plane.
body of the mandible, about the level of the bicuspids.
The inner surface of the mandible has a bony ridge (the
Normal CT Anatomy
mylohyoid line) for the origin of the mylohyoid muscle and
a slight depression (the digastnic fossa) for that of the Because of its irregular configuration, only segments of
anterior belly of the digastnic. Just superior to the mylohyoid the mandible are contained within a given CT section (fig.
attachment is the sublingual gland and inferior to it is an 2). Axial scans at the level of the temporomandibular joint
oval fossa for the submandibular gland (figs. 1 B and 1 C). demonstrate the ovoid, somewhat obliquely oriented man-

Received March 19, 1982; accepted after revision June 2, 1982.

Presented in part at the American Society of Head and Neck Radiology, Los Angeles. May 1 981.
, Department of Radiology, University of Utah School of Medicine, 50 N. Medical Dr., Salt Lake City, UT 84132. Address reprint requests to A. G. Osborn.
2 Department of Radiology. UCLA Center for the Health Sciences, Los Angeles, CA 90024.
AJR 139:555-559, September 1982 0361 -803X/82/ 1 393-0555 $00.00 © American Roentgen Ray Society
 556 OSBORN ET AL. AJR:139, September 1982
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Fig. 1 -Frontal (A). lateral (B), and posterosuperior (C) views of

dried adult mandible with normal complement of teeth. 1 = mandibular
body, 2 = mandibular namus, 3 = mandibular angle, 4 = condyle, 5
= coronoid process, 6 = alveolar ridge, 7 = mental fonamen, 8 =

mandibular foramen, 9 = lingula, 1 0 = submandibular fossa, 11 =

mylohyoid line, 1 2 = mental protuberance, 13 = symphysis menti, 14

= attachment for genioglossus muscle, 15 = digastnic fossa, 16 =
tuberculum, 1 7 = tuberosities for attachment of medial pterygoid
muscle.

dibulan condyles lying within the articulan fossae. At this symphysis are seen on slightly lower cuts (fig. 3F). The
level, the articular eminence is seen as a slightly curvilinear mental foramina are often not well depicted.
structure lying just anterior to the condyle. The condyle is
separated from the external auditory canal by the tympanic
Pathologic CT Anatomy
part of the temporal bone (fig. 3A).
Scans 1 cm below the mandibular condyles include the Case 1
triangular mandibular neck. It is separated from the smaller,
An 8-year-old boy with eosinophilic granuloma had diffuse in-
elongated cononoid process by a hiatus, the mandibular
volvement of the skull and facial bones. CT scans demonstrated the
notch (fig. 36). Scans through the body of the mandibular
typical appearance of floating teeth’ and lytic lesions in both
namus demonstrate a thin, flat, bony plate with a slight mandibular rami (fig. 4). Compare this study with the normal ex-
medial concavity (fig. 3C). The middle of the mandibular ample (fig. 3D).
namus is perforated on its inner surface by the obliquely
oriented mandibular foramen (fig. 3D). The mandibular for-
amen is overlapped by a thin bony lamella, the lingula. Case 2
Scans through the alveolar process include the partially A 31 -year-old woman complained of an intermittently tender right
sectioned teeth (fig. 3E). The mental protuberance and facial mass accompanied by diminished sensation in the ipsilateral
 AJR:139, September 1982 CT ANATOMY OF MANDIBLE 557

cheek and ear. Physical examinatioii disclosed a 3 x 4 cm hard Case 3

mass medial to the mandibular condyle. CT scans disclosed an
A 43-year-old woman had several operations and radiation then-
osteoma arising from the skull base, thinning and bowing the ramus apy for a parotid lymphangioma. CT scans showed a lipomatous
laterally (fig. 5). mass extending into the infratemporal and paranasopharyngeal
spaces. The entire left half of the mandible showed massive, irreg-
ular, bony hypertrophy (fig. 6). Final pathologic diagnosis was
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lipolymphangioma.

Case 4

A 47-year-old woman had a 20 year history of recurrent mass in

the left mandible. CT disclosed a large, cystic, expansile lesion in
the mandibular body and ramus (fig. 7). Pathologic diagnosis was
cystic ameloblastoma or ameloblastoma with aneurysmal bone cyst.

Case 5

A 32-year-old woman had pain in the left jaw for 1 month. There
was a small mass near the angle of the mandible. CT scans
Fig. 2.-Sketch of disarticulated mandible with CT planes illustrated in
figure 3 indicated. Scans were obtained at +15 to +20 from orbitomeatal disclosed mixed areas offluid-filled cysts and solid tissue expanding
line. the body and ramus of the mandible (fig. 8). Invasion of the medial

E F
1-ig. 3.-A, Axial CT scan through temporomandibulan joints. Note #{224}ngu- ular rami (arrows). D, Axial CT scan 1 cm below C. 8 = mandibular fonamen,
lation between true coronal plane and axis of mandibular condyles. 4 = 9 = lingula, 24 = maxillary alveolus. E, Axial CT scan through mandibular
mandibular condyle, 1 8 = articulan eminence, 1 9 = temporomandibulan joint body (arrows) and alveolan ridge (arrowheads). F, Axial CT scan 1 cm below
space, 20 = tympanic part of temporal bone, 21 = external auditory canal. E. Mental protuberance (arrow). Attachment of genioglossus muscle (arrow-
B, Axial CT scan 1 cm below A. 5 = coronoid process, 22 = mandibular head).
notch, 23 = neck of mandibular condyle. C, Axial CT scan through mandib-
 558 OSBORN ET AL. AJR:139, September 1982
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Fig. 4.-Case 1 . Axial CT scan through mandibular nami of patient with Fig. 7.-Case 4. CT scan without contrast in patient with cystic amelo-
diffuse eosinophilic granuloma. Nearly symmetrical lytic lesions (arrows). blastoma of mandible (arrows). Note discontinuity of osseous rim and pres-
Fig. 5.-Case 2. CT scan without contrast. Osteoma arises from skull sure deformity of adjacent maxillary sinus.
base (arrows). Right mandibular namus is bowed around lesion (arrowhead). Fig. 8.-Case 5. CT scan without contrast. Expansile lesion in mandibular
Note pseudoarticulation with adjacent pterygoid plates. ramus (arrows). Other sections disclosed cystic-appearing lesions mixed with
Fig. 6.-Case 3. CT scan without contrast. Low attentuation mass (arrow- foci of solid tissue in mandibular body. Note medial discontinuity of bony rim
heads) surrounds massively hypentrophied mandibular ramus. Lesion extends and extension into ptenygoid muscle. Adamantinoma was found at surgery.
into medial pterygoid muscle and parapharyngeal space. Lipolymphangioma Fig. 9.-Case 6. CT scan without contrast. Lange fibrosarcoma of night
was found at surgery. mandible (arrows). Note erosion, destruction of namus (arrowheads).

pterygoid muscle was diagnosed and confirmed at surgery. Patho- by routine plain films, panoramic tomography, or intraoral
logic diagnosis was adamantinoma. radiography, CT is of unique value in delineating those
lesions that have both osseous and soft-tissue extension.
Involvement of the infratemporal and parapharyngeal
Case 6 spaces, oral cavity, skull base, and other adjacent structures
can be readily determined. In such cases, CT may provide
A 1 5-year-old girl was well until she noted pain in her right lower
crucial information unobtainable by any other diagnostic
jaw. Dental extraction of the right mandibular third molar was
complicated by active bleeding. Persistent pain and soft-tissue
method and alter subsequent treatment planning. CT is also
swelling prompted oral radiography which showed a large permea- helpful in excluding involvement by primary osseous or soft-
tive, destructive lesion in the right ramus. CT scans disclosed a lytic tissue lesions adjacent to the mandible, but we have found
lesion with an extensive soft-tissue component (fig. 9). Grade II it is of little value in examining most congenital anomalies,
fibrosarcoma was found at biopsy. uncomplicated trauma, and abnormalities limited to the den-
tition or cancellous bone of the mandible.

Discussion REFERENCES

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