ROLE OF MRI IMAGING IN

ORAL & MAXILLOFACIAL

SURGERY

SEMINAR BY: VIJETA SINHA

II YEAR PG
INTRODUCTION
 Magnetic resonance imaging (MRI) is one of the most powerful
diagnostic tools in radiology and diagnostic science.
 It is a non-invasive procedure and the images can be highly sensitive
and specific.
 The system does not use ionizing radiation and there is little risk
associated with application of magnetic field to the majority of
people.
HISTORY
WHAT IS MAGNETIC RESONANCE IMAGING?
MRI uses radiowave “dialog” with
the patient’s tissues and lesion
within a magnetic field.
Soft tissues are composed of 70%-90%
water, which is concentrated hydrogen
nuclei composed of solitary protons
hence soft tissues are proton rich.

The properties and amount of water within a

tissue can alter drastically with disease or injury,
to which MRI is very sensitive .

MRI images are obtained by measuring how

rapidly hydrogen nuclei of different tissues
return to their resting energy states after being
excited by a strong magnetic field.
 The Magnetic Resonance Imaging Process
1.The patient is placed in a
magnetic field and essentially
becomes a magnet.
2. A radio wave is sent in.
3. The radio wave is turned off.
4. The patient emits a signal
5. The signal is received and used
for reconstruction of the picture.
WORKING PRINCIPLES OF MRI
• The patient is placed within a very strong
magnetic field (usually between 0.5-1.5 Tesla).

• The patient's hydrogen protons, which normally

spin on an axis, behave like small magnets to
produce the net magnetization vector (NMV)
which aligns itself readily with the long axis of
the magnetic field.

• This contributes to the longitudinal magnetic

force or magnetic moment which runs along the
long axis of the patient.
• Radiowaves are pulsed into patient by the body coil transmitter at 90° to the
magnetic field.

• These radiowaves are chosen to have the same frequency as the spinning
hydrogen protons. Their long axes move away from the long axis of the main
magnetic field causing the longitudinal magnetic moment to diminish and the
transverse magnetic moment to grow.

• This magnetic moment now lies transversely across the patient and induces an
electrical current in a receiver.

• Surface coils act as receiver coils forming MR signals.

• The MR signal data is analysed by a computer to form a tomographic image in

the axial, coronal or sagittal planes.
T1 AND T2 WEIGHTED IMAGES
• The hydrogen protons (NMV) relax and their acquired energy is lost.
• There are two types of relaxation processes:
Spin-lattice: also known as the longitudinal proton relaxation time or
the T1‐weighted sequence
Spin–spin: also known as the transverse proton relaxation time or the
T2‐weighted sequence.
T1 WEIGHTED/ ANATOMY SCANS
• Their Images display excellent
contrast and show the
boundaries between different
tissues.
• In such images tissues with fast
T1 times, such as fat, will appear
bright, whereas those with long
T1 times, such as CSF ,water will
appear dark.
T2 WEIGHTED/ PATHOLOGY SCANS
• They are called so because
collections of abnormal fluid are
bright against the darker normal
tissue
• These are also called ‘water images’
• Useful for detecting infection,
hemorrhage, and neoplasms
• In such images tissues with long T2
times, such as CSF for
temporomandibular (TMJ) joint
fluid, appear bright, whereas
tissues with short T2 times, such as
fat, appear dark.
Signal intensity of different tissues in T1 – and T2-
weighted MRIs
CLOSED & OPEN MRI

• There are two main types of

machine:
Open: it has two flat magnets above
and below with space between for
patient to lie ; used for claustrophobic
patients
Closed: it has a ring of magnet with a
hole in between for patient to lie
down; increases anxiety and
discomfort but takes best quality
images
DYNAMIC CONTRAST ENHANCED MRI
• rapid sequential MR images obtained through an area of interest before, during, and after
a bolus administration of contrast material
• The process of gadolinium leakage from intravascular-to-extravascular compartments
depends on
blood flow to tissue,
microvascular attenuation,
vascular permeability, and
fractional volume of extracellular extravascular space that can be assessed by DCE–MR
imaging.

• examines microvascular tumor tissue characteristics

• assess the reduction of tumor blood perfusion by means of K(trans), which represents the
volume transfer constant from the vascular to the extravascular extracellular spaces
• CLINICAL APPLICATIONS:
differentiates squamous cell carcinoma from lymphoma and
undifferentiated carcinomas,
detects metastatic lymph nodes,
 assesses tumor cell proliferation and microvessel attenuation,
 predicts early treatment response and treatment outcome
Pretreatment gadolinium-enhanced axial T1-weighted MR imaging
of the neck demonstrating metastatic right level IIb lymph nodes

Parametric maps (C, D, and E) show higher volume transfer

constant

Axial contrast-enhanced neck CT

at 6 months post-chemoradiation
treatment showing favorable
response to treatment
ADVANTAGES
• Ionizing radiation is not used
• No adverse effects have yet been demonstrated
• Image manipulation available
• High-resolution images can be reconstructed in all planes (using 3D volume
techniques)
• Excellent differentiation between different soft tissues possible
• differentiation between benign and malignant disease and between
recurrence and postoperative effects
• Useful in determining intramedullary spread.
DIS-ADVANTAGES
• Scanning time can be long and is thus demanding on the patient
• It is contraindicated in patients with certain types of surgical clips,
cardiac pacemakers, cochlear implants and in the first trimester of
pregnancy
• Equipment tends to be claustrophobic and noisy
• Metallic objects, e.g. endotracheal tubes need to be replaced by non-
ferromagnetic alternatives
• Equipment is expensive
• Bone, teeth, air and metallic objects appear black, making
differentiation difficult
APPLICATIONS
 For non-invasive evaluation of the integrity and position of articular disk with
in the TMJ.
 Investigation of the TMJ to show both the bony and soft tissue components of
joint including disc position:
a. When diagnosis of internal derangement is in doubt
b. As a preoperative assessment before disc surgery
For the diagnosis and evaluation of benign and malignant tumors of jaws.
Tumor staging evaluation of the site, size and extent of all soft tissue tumors
and tumor like lesions, involving all areas including.
a. salivary glands
b. pharynx
c. Sinuses
d.orbits
To evaluate structural integrity of trigeminal nerve in trigeminal
neuralgia.
In surgery of parotid gland MRI can detect the cause of facial nerve
within the glandular tissue and help lessen the likelihood of post-
operative facial nerve palsy.
 For the assessment of intracranial lesions involving particular posterior
cranial fossa, the pituitary and the spinal cord.
examination of the maxillary sinuses, masseter muscles
 detection of early bone changes such as tumors, fractures, inflammatory
conditions and hematoma
TEMPORO MANDIBULAR JOINT
• MRI is currently the gold standard for diagnosing disc disorders.
• The standard MR imaging protocol consists of oblique sagittal and
coronal proton density-weighted (PDWI) sequences in closed- and
open-mouth positions.
• Images acquired perpendicular or parallel to the long axis of the
mandibular condyle.
• T2WI detects degenerative periarticular changes and the presence of a
joint effusion.
• Gadolinium contrast is not used routinely but would be indicated in
infection, inflammatory arthropathy, or neoplasm is suspected.
Normal Temporomandibular joint MRI.
(A) closed mouth position shows normal location and bow-tie appearance of the articular
disc with anterior (straight arrow) and posterior bands (curved arrow). The
mandibular condyle (star) is in an anatomic location within the mandibular fossa.

(B) open mouth normal condylar rotation and anterior translation

Anterior disc displacement with recapture
(A) closed mouth position shows anterior displacement of the articular disc with otherwise
normal bow-tie appearance (straight arrow). The mandibular condyle is situated in an
anatomic location within the mandibular fossa.
(B) Open mouth position shows normal condylar rotation and anterior translation with
recapture of the articular disc, which is now in the normal position (curved arrow). The bow-
tie appearance of the articular disc is preserved.
MALIGNANCIES
• Owing to excellent soft tissue
contrast and multi planer views,
MRI delineates tumor size and
thickness, local extension into
surrounding structures, perineural
invasion and bone infiltration

• MRI also determines the depth of

invasion preoperatively which is one
of the primary predictors of the
nodal metastasis
• Axial post contrast T1 fat sat image
shows a large enhancing mass lesion in
right lateral border of tongue with
contralateral extension.
Coronal T1 fat saturated image with
contrast shows tumor extending
laterally invading and eroding the
right mandible.
• MRI is also used to assess the
extent of lymphadenopathy.
• Commonly used parameters of the
nodal involvement on conventional
MR imaging techniques are
size,
shape and
central necrosis.

Presence of central necrosis is the

most reliable sign of malignancy
T2-weighted MRI ( axial and coronal)
showing median lingual lymph node
metastasis in the lingual septum.
TRAUMA
• Used for assessing for TM disc disruption or capsular tear which can
occur with high condylar fractures.
• Because of its superior soft-tissue contrast and multiplanar capabilities,
MRI may help detect a CSF leak from a skull base fracture.
• MRI can aid in diagnosing the contents that have herniated through a
defect in skull base injuries
• It has an adjunctive role to CT in the assessment of orbital soft tissues
and particular blow out fractures
• A rare complication of skull base trauma carotid – cavernous sinus
fistula; MRI and MR angiography are helpful
Patient with dislocated mandibular condyle fracture.

• (c) is antero inferiorly displaced. The TMJ disk (d) is located superior to the fractured
fragment but is antero inferiorly displaced relative to the remaining mandibular ramus.
The tear of the infero posterior attachment of the disk (black arrow on A) is shown.
• T2-weighted image (B) demonstrates the dotted high signal intensity of retro discal tissue
(black arrow), joint effusion of the upper joint compartment (e), and well-defined
superior posterior attachment (black arrowhead) of the disk.
• Coronal proton attenuation-weighted image (C) reveals the tear of the joint capsule (black
arrows) and fractured fragment (c) located on the medial side of the mandibular ramus.
SALIVARY GLANDS
• MRI has highest sensitivity and specificity hence used for differential diagnosis
between benign and malignant salivary gland tumors
• MR sialography is used to evaluate the ductal system of the major salivary glands
without requiring use of IV or ductal contrast agents.

T2 segmentation images of
salivary glands
Magnetic resonance imaging (MRI) of the submandibular glands. MRI
demonstrating a sharply margined mass with relatively homogeneous T2 hypointense filling defects with T2
contrast enhancement. hyperintense saliva within right submandibular
(A) Coronal section. duct indicating ductal sialolithiasis with mild
(B) Transverse section.  sialadenitis
T2 axial MRI showing a case of pleomorphic adenoma, well-
circumscribed, T2-bright left parotid gland

Salivary duct carcinoma case. Axial T2 (A) of a 73 year-old male.

The lesion is well delineated and hyperintense on T1-weighted
images (B).
INFECTIONS

• Emergency neck MRI can accurately detect odontogenic

abscesses and reliably point to the causative tooth.
• These results can increase the utility and reliance on emergency
MRI in clinical decision-making.
T2 axial weighted MRI showing MRI showing involvement of buccal,
involvement of buccal space submandibular and pharyngeal spaces
Transversal images of
A, FDG-PET,
B, MRI (T1-weighted plus gadolinium-diethylenetriaminepentaacetic acid),
C, PET/MRI fusion
CONCLUSION

• MRI is a complex but effective imaging system that has a variety of

clinical indications directly related to the diagnosis and treatment of
oral and maxillofacial abnormalities .
• While not routinely applicable in dentistry, appropriate use of MRI can
enhance the quality of patient care in selected cases.
• Further advances in 3D imaging and dynamic scanning has enhanced
the use of this imaging technique even further leading to better
prognosis.