ROLE OF MAGNETIC RESONANCE IMAGING IN DENTISTRY

C. D. Nayak , S.S.Pagare, Amarinder Kaur

Abstract
MRI (Magnetic Resonance Imaging) is one of the latest techniques which gives excellent soft tissue definition. It is useful in neurological (brain), musculoskeletal, cardiovascular, and oncological (cancer) imaging. It has the advantage of being a non ionizing technique. This article gives an insight of use of MRI in Dental & Maxillofacial disorders.

Introduction
Physiological studies both under normal and pathological conditions have always been important to medical science. Many major technological advances have been applied in clinical research such as CT, USG and MRI. Of these MRI has proved to be the most versatile. Since its introduction as a clinical tool in the early 1980s the progress of magnetic resonance imaging has been phenomenal. Magnetic Resonance Imaging (MRI)2 provides detailed images of the body in any plane. MRI provides much greater contrast between the different soft tissues of the body, making it especially useful in neurological (brain), musculoskeletal, cardiovascular, and oncological (cancer) imaging. It uses no ionizing radiation, but uses a powerful magnetic field to align the nuclear magnetization of (usually) hydrogen atoms in water in the body. Radiofrequency fields are used to systematically alter the alignment of this magnetization, causing the hydrogen nuclei to produce a rotating magnetic field detectable by the scanner. This signal can be manipulated by additional magnetic fields to build up enough information to reconstruct an image of the body.
Professor , Professor & HOD , PG Student Department Of Oral Medicine And Radiology, Dr. D. Y. Patil Dental College And Hospital , Nerul, Navi Mumbai.

History
In 1970, Raymond Damadian, a medical doctor and research scientist, discovered the basis for using magnetic resonance imaging as a tool for medical diagnosis The first MR Image was published in 1973 and the first study performed on a human took place on July 3, 1977. The 2003 Nobel Prize in Physiology or Medicine was awarded to Paul C Lauterbur and Peter Mansfield for their discoveries concerning magnetic resonance imaging1.

Applications of MRI in Dentistry

Magnetic resonance imaging is fast outpacing modality for in vivo viewing of soft tissues in the human body without the need to resort to invasive procedures or exposure to dangerous radiation. Although conventional dental X-rays will continue to be used in dentistry, the scope of dentistry is expanding and subsequently the need for imaging. The significant advantage of MRI over the other modalities is its ability to distinguish among various soft tissues as stated by Brooks and Miles. Its indications include inflammatory and neoplastic lesions of the nasopharynx, salivary glands, paranasal sinuses as well as orbits and intracranial structures3. So far, MRI has proved to be most valuable in the diagnosis of internal derangement of the temporomandibular joint (TMJ) due to its ability to define the cartilaginous disk. Katzberg, Westesson10, Latchaw et al noted that anterior disk displacement is easily detected when both sagittal and coronal views are obtained.
Vol. III - 2009

Scientific Journal

Role of Magnetic Resonance Imaging In Dentistry --------------------------------------------------- C.D. Nayak et al

Westesson et al. performed MRIs 2 years postoperatively after vertical ramus osteotomy in 10 patients and found imaging to be an excellent method to study morphological changes of the muscles of mastication for and osseous fragments when compared to controls. Traxler et al. studied the relevance of MRI for diagnosing tumors of the parotid gland. MRI is more superior as compared to CT and USG in diagnosing muscle hypertrophy. In clinical endodontics there is need for improved diagnostic methods for accurate pulp pathosis and configuration of root canals. Lockhart et al. had imaged extracted human teeth to establish possible future applications of MRI in pulp pathosis. They reported high accuracy of MRI in images of periodontal membrane and gross pulpal anatomy. However, due to limitation of slice thickness, detailed resolution was poor. Bauman et al. used stray field imaging (STRAFI), a newly developed and as yet experimental magnetic resonance microscope , for imaging carious mandibular molar root canals and pulp chamber. Magnetic fields used were high and time taken for data collection was 8-10 hrs while image reconstruction took 1 hour. Inspite of drawbacks, MR microscopy may open a new dimension of non-destructive image reconstruction.

MRI has the ability to differentiate between solid and cystic lesions which is especially important in the evaluation of jaw tumours6. It is the only imaging modality capable of demonstrating perineural spread of a tumour by branches of trigeminal and facial nerves and can also detect early cortical erosion and marrow involvement. MR evaluation of maxillary pathological conditions includes both axial and coronal T1 weighted images to assess the distribution of the lesion and its extension beyond the cortex of the bone of origin. Coronal images ideal for assessing the transcortical extension of maxillary lesions into orbits, alveolus, palate or more whereas axial images facilitate the detection of tumour spread into the pterygopalatine regions and soft tissue regions of the cheek. T2 weighted images demonstrate extraosseous spread of tumor, are useful in differentiating tumor from sinus mucosa or retained sinus secretions. In the mandible, axial images are particularly useful for assessing the symphyseal region. Coronal images are more valuable for the evaluation of the tumor spread to or through the floor of the mouth and assessment of the tumor to the inferior dental nerve.

Maxillofacial Disorders

Fig 1: T1-Wt Image Shows Hypointensity That Encroaches On The Left Pterygopalatine Fossa.

Fig 2: Contrast Enhanced T1-Wt Images Show Tumoral Enhancement

Scientific Journal

Vol. III - 2009

Role of Magnetic Resonance Imaging In Dentistry --------------------------------------------------- C.D. Nayak et al

Fibrous Dysplasia
Fibrous dysplasia4 is an idiopathic disease in which medullary bone is replaced by disorganized fibroosseous tissue. An MR signal is hypointense on all sequences.Foci of bright signal intensity are intermixed with the more typical hypointense signal of fibroosseous tissue on both T1 and T2 weighted images (Fig 1).

and displacement of adjacent structures may also be often evident. After surgery, MRI can demonstrate the presence of early recurrences, which appear bright on T2-wt images.

Temporomandibular Joint
Temporomandibular joint is ideally suited for investigation with MRI because it allows simultaneous bilateral imaging, both joints can be examined efficiently8 (Fig 5 A, B). A routine MRI evaluation of TMJ consists of a series of acquisitions. Images are obtained in the axial plane to define the location of the joints and provide a global view of the surrounding anatomy. Coronal images are routinely obtained because they provide information about mediolateral relationships at the TMJ. The sagittal images are assigned from the axial in an oblique plane corresponding to the axis of the condyle and body of the mandible10. These oblique sagittal images provides the greatest diagnostic detail for anatomical diagnosis.The TMJ9 can be examined with all clinically available magnet strengths. Although early reports of TMJ MRI used midfield imagers (0.3 to 0.6 Tesla), more recent reports have emphasized high field imaging (1to2 Tesla)9.

Osteosarcoma
On MR examinations, osteosarcomas5 typically present as a soft tissue masses associated with osseous destruction.The soft tissue mass exhibits low to intermediate signal intensity on T1 weighted images (Fig 2) and high signal intensity on T2 weighted images.MR imaging usually permits demarcation of the tumor from the adjacent bone marrow in T1-weighted images or extraosseous soft tissue in T2 weighted images.

Dentigerous Cyst
On MR examination, the cystic fluid exhibits low to intermediate signal intensity on T1-wt images and high signal intensity on T2- wt images (Fig 3), whereas the partially completed crown appears as an area devoid of signal or of low signal because of its low mobile proton density. The cyst wall is of intermediate intensity on T2-wt images (not as bright as sinus mucosa).

Ameloblastoma
MRI can provide important information concerning ameloblastomas7. This technique can help differentiate between cystic and mixed cystic solid lesions. The nature of the lining epithelium can be studied, and early extension into the adjacent soft tissues can be detected. Solid and cystic components are usually hypointense on T1-wt images with solid tumors demonstrating a more homogeneous appearance. Purely cystic areas have been noted to exhibit low signal intensity on T1-wt images (Fig 4) and high signal intensity on T2-wt images. Cortical expansion
Scientific Journal

Fig 3: Dentigerous Cyst On T1 And T2- Wt Images

Fig 4: Unicystic Ameloblastoma On T1-Wt

Vol. III - 2009

Role of Magnetic Resonance Imaging In Dentistry --------------------------------------------------- C.D. Nayak et al

MR images of Sjogrens syndrome 11,12 demonstrate an enlarged parotid gland with an inhomogeneous speckled or nodular pattern (salt and pepper appearance) on T2-wt images (Fig 6). Overall signal intensity decreases on T2-wt images as compared with normal controls.

Discussion
The benefits of MRI are substantial because of its excellent soft tissue contrast, lack of artefact from adjacent tissue, multiplanar capabilities and lack of ionizing radiation. The chief strengths of MRI are its ability to provide cross-sectional images of anatomical regions in any plane and its excellent soft tissue contrast. New applications are continually being developed as the technique and equipment undergo refinement. Inspite of its present selective and restrictive uses due to its costs, MRI quality has already set it apart from other imaging modalities and it is only a matter of time before its use in dentistry is an everyday occurrence.

Fig 5 (A,B): Left TMJ Region The Anterior Displacement Of Articular Disc Without Reduction Can Be Observed At (A) A Proton Density-Weighted Imaging ( PDWI ) Slice At Closed Mouth and (B) A PDWI Slice at Open Mouth.

Summary and Conclusion Sjogrens Syndrome

Of many major technological advances such as Computed Tomography, Ultrasound that have been applied in clinical research, Magnetic Resonance Imaging has proved to be the most versatile. The clinical significance of MRI is reflected by the extra ordinary growth of MR scanner worldwide, (worldwide-9000 scanners ; North America45000 scanners , Japan-3400 scanners). MRI has the ability to generate high resolution multiplanar (3D) images in addition to providing superior contrast resolution . Thus MRI is a pre- eminent soft tissue diagnostic modality for many neurological, musculoskeletal, cardiac and maxillo-facial pathologies.

Fig 6: T2-Wt Coronal Image: Sjogrens Syndrome

Scientific Journal

Vol. III - 2009

Role of Magnetic Resonance Imaging In Dentistry --------------------------------------------------- C.D. Nayak et al

References
1. Lauterbur, P.C. "Image Formation by Induced Local Interactions: Examples of Employing Nuclear Magnetic Resonance". Nature 1973; 242: 190-191. David D. Stark, William G. Bradley , MAGNETIC RESONANCE IMAGING , 3RD Edition Wu, Y.; Chesler, D.A.; Glimcher, M.J.; Garrido, L.; Wang, J.; Jiang, H.J.; Ackerman, J.L. "Multinuclear solid-state three-dimensional MRI of bone and synthetic calcium phosphates". Proc Natl Acad Sci US 1999; 4: 15741578 Fibro-osseous lesions : the role of imaging. Radiol Clin North America 1993; 31: 121. Seeger L L, Widoff, Basset et al : Preoperative evaluation of osteosarcoma: value of gadopentate dimeglumine enhanced MR imaging , American J Roentgenology 1991; 157:347. Van Resenburg LJ, Nortje CJ et al: Magnetic resonance imaging and computed tomography of malignant disease of the jaws , Oral Maxillofacial Surg Clin North America 1991; 4 : 1 75. 7. Manabu Minami,Takashi Kaneda et al Ameloblastoma in the Maxillomandibular Region: MR Imaging. Radiology 1992; 184:389-393 Donlon WC and Moon KL : Comparison of MRI , arthrogragphy and clinical and surgical findings in TMJ derangements , Oral surgery, oral medicine , oral radiology ,endod 1987; 64:2. Steven E. Harms, M.D.Randall M. Wilk et al, The Temporomandibular Joint:Magnetic Resonance Imaging UsingSurface CoilsRadiology 1985; 157:133-136 Richard W. Katzberg, Per-Lennart Westesson et al Temporomandibular Joint: MR Assessment of Rotational and Sideways Disk Displacements Radiology 1988; 169:741-748 Louis M Teresi, Robert B. Lufkin et al, Parotid Masses:MR ImagingRadiology 1987; 163:405-409 Spath M, Kruger K et al : MRI of Parotid gland in patients with Sjogrens syndrome, JR of Rheumatology 1991; 18:1372.

2.

8.

3.

9.

4.

10.

5.

11.

6.

12.

Scientific Journal

Vol. III - 2009