ADVANCED MODALITIES IN MAXILLOFACIAL IMAGING

COMPUTED TOMOGRAPHY

 CT scanners were first introduced in 1971 by Sir Godfray Hounsfield, an electrical engineer at
Electric and Musical Industries Ltd.

 Computed tomography (CT) scanning, also known as computerized axial tomography (CAT)
scanning, is the diagnostic imaging modality which uses X-rays to construct a cross-sectional
image of a particular portion of the body.

 CT image is produced by the process of reconstruction-X-rays which will pass through the
patient at different angles and attenuated in different tissue depending upon their attenuation
coefficient.

 STEPS:-

 S1.X-ray exposure from CT machine to the patient,

 S2. After striking to the patient some radiation attenuates and some pass to the detectors,

 S3Detectors form an image in the form of "pixel" and "voxel". Voxel (volume elements) is a
matrix of individual blocks called voxels, while Pixel (picture elements) is each square of the
image matrix.

 S4. After exposure to x-ray (which is passed through patient), each pixel attenuates/absorbs
beam the intensity of beam depends on the density of the body surface/lesion, to which it was
exposed.

 S5For an example in case of a bone lesion much radiation cannot pass from the body and reach
less to the detector, while reverse for any fluid lesion like cyst).

 S6The detector will give attenuation coefficient based on intensity of radiation strike to the
detector.

 S7After calculating the linear attenuation of all the pixels, the value is converted to number
called CT number which ranges from-1000 (for air) to 1000 (for dense bones).

 S8 This numerical representation of image is called "digital image.

 S9 After assigning CT number next steps of computer is the conversion of the digital image to
grey scale imaging called windowing.

 S10There are two types of windows in CT Le. soft tissue window and hard tissue window.

 S11In soft tissue window, muscles, skin, salivary glands, blood vessels appear gray andclear
compared to bone which appears heavy white while fatty subcutaneous tissues, air sinuses-
appears black.
  S12 In hard tissue window, bone is clearly seen, but other soft tissue remained in single grey
color.

 S13 So if we want to see bone pathology, hard tissue window mode should be pressed on the
computer, while to see changes on the soft tissue like parotid gland, soft tissue window mode
should be used.

 S14The 2 demensional image can be converted into 3 dimensional called as interpolation.

Interpretation:-

Hypo-dense: Any structure that appears dark as compared to the surrounding tissue.

Hyper-dense: Any structure that appears bright as compared to the surrounding tissue.

Iso-dense: The structure that appears in same density as that of surrounding tissue.

Advantages of CT

 Accessibility, less expensive, less time consuming is more as compared to MRI.

 Accuracy in diagnosing pathologies helps in proper management of the patient.
 Multiplanar reconstruction of the volume data can be done.
 Three-dimension surface shaded rendering is also possible for bones and soft tissues.
 Volume rendering is an advanced rendering technique that displays an entire volume.
 Diagnostic as well as therapeutic procedure can be done in CT.

Disadvantages of CT

 It uses ionizing radiation; hence repeated use is not recommended.

 Not used in pregnant female and lactating mothers.
 The contrast agents given in CT can lead to anaphylactic reactions, so should be avoided in
elderly patient with compromised renal function, asthma and multiple myeloma.
 MRI

Mechanism: -

 Magnetic resonance imaging (MRI) is fast outpacing any other modality for in
vivo viewing of soft tissues in the human body without the need to resort to any
invasive procedures.

 MRI scan is a specialized imaging technique which does not use ionizing radiation.

 Hydrogen is found in abundance in soft tissue but is lacking in most hard tissues.

 MRI involves the behaviour of hydrogen atoms (consisting of one proton and one
electron) within a strong magnetic field which is used to create the MR image.

 This causes the nuclei of many atoms in the body to align themselves with the
magnetic field. The machine applies a radiofrequency pulse to depolarize the atoms
and the energy that is released from the body is detected and used to construct the
MR image by a computer.

Advantage

 The high contrast sensitivity of MRI to soft tissue and offers the best resolution of
tissues of low inherent contrast.

 Susceptible malignant neoplasm of oral cavity can only be visualized with MRI.
Because the region of the body imaged in MRI is controlled electronically, direct
multiplanar imaging is possible without reorienting the patient.

 MRI offers best soft-tissue lesions in salivary glands, TMJ and tumour staging. Its
exceptional soft- tissue contrast resolution makes it ideal for detection of internal
derangement of TMJ.

 MRI can also detect joint effusions, synovitis, erosions and associated bone marrow
oedema. Odontogenic cysts and tumors can be distinguished better on MRI than on CT.

 It also identifies soft tissue diseases, especially neoplasia, involving tongue, cheek,
salivary glands, neck and lymph nodes.
Disadvantages

1. claustrophobia
2. steel oriented instruments could not be used during imaging due to strong magnetic
fields.
3. Long imaging times
4. Relatively costlier for usage and purchase.

Interpretation:
1. hypertense
2. isotense
3. hypotense
 Ultrasound

 Ultrasound is a non-invasive, inexpensive and painless imaging method. Unlike X-rays,

it does not cause harmful ionizing radiation.
 Ultrasonogram can be used for both hard and soft tissue detection.
 The high-frequency ultrasound beam is directed into the body from a
transducer placed in contact with the skin.
 Jelly is placed between the transducer and the skin to avoid an air interface.
 As the ultrasound travels through the body, some of it is reflected by tissue interfaces
to produce echoes, which are picked up by the same transducer and converted into an
electrical signal and then into a real-time black, white and grey visual echo picture,
which is displaced on a computer screen.
 Ultra sonogram is based on the reflection of sound waves (echoes) with a frequency
outside the range of human hearing (1-20 kHz), at the interface of tissues which have
different acoustic properties.
 Ultrasonic waves are created by the piezoelectric effect within a transducer (probe).
 Ultrasound waves transmit energy, as X-ray does, but it requires a medium for its
transmission, unlike X-rays which pass readily through a vacuum.
The echoes are detected by a transducer which converts them into an electrical signal and a
real-time black, white and shades of grey picture is produced on a computer screen.

Different modes: -

 A-mode displays signal amplitude versus depth as a one-dimensional graph

[Ophthalmological purpose].
 B-mode generates a two-dimensional, grayscale image from signal brightness.
 M-mode tracks the motion of structures over time on a specific ultrasound. line.
 Doppler mode specifically visualizes blood flow, using color to indicate direction and
speed, which is crucial for assessing circulation.

Indications: -

 Evaluation of swellings of the neck, particularly those involving the thyroid, cervical
lymph nodes or the major salivary glands – ultrasound is now regarded as the
 Investigation of choice for detecting solid and cystic soft tissue masses
 Detection of salivary gland and duct calculi
 Determination of the relationship of vascular structures and
 vascularity of masses with the addition of colour flow
 Assessment of blood flow in the carotids and carotid body.

Interpretation:-

1. Hypoechoic
2. Isoechoic
3. Hyperechoic