t?

1996 The Bntlsh Assocmtion of Oral and Maxdlofacial Surgeons

The use of magnetic resonance imaging to assessswelling after the

removal of third molar teeth
J: Llewelyn, M. Ryan, C. Santosh
Department of Maxillofuciul and Oral Surgery, Royal Gwent Hospital, Newport, UK; Department of
Muxilloj~cial Surgery, The City Hospital, Edinburgh, UK; University Department of Radiology, Universit!,
qf Edinburgh, Edinburgh, UK

SUMMARY.
Objective-To assessthe suitability and accuracy of magnetic resonance imaging (MRI) in measuring
the swelling of the face and lingual tissues after removal of third molar teeth. Design-Prospective open study.
Setting-Teaching hospital, Scotland. Subjects-5 patients 19-22 years old with bilateral mesioangular impacted
wisdom teeth. Interventions-Magnetic
resonance imaging scans taken before, and 1 and 7 days after, removal of
bilateral lower wisdom teeth under general anaesthesia. Main outcome measures-Amount
of swelling measured
postoperatively compared with preoperatively. Coefficient of analytical variation calculated for the main observer,
and between him and a second observer to assess accuracy and reproducibility for each examiner and between
examiners. Results-Buccal
swelling on the first postoperative day was significantly greater than preoperative
(P<O.Ol). There was no significant difference in lingual swelling. The mean coefficient of variation for the first
examiner was 1.92 and there was no significant difference between the two examiners. Conclusions-Measurements
on MRI scans are both recordable and reproducible for buccal swelling, but lingual swelling is more diflicult to
measure because of problems in defining the lateral border of the tongue. MRI scans provide an objective measurement
of swelling after extraction of wisdom teeth and could be used to evaluate the efficacy of drug regimens.

INTRODUCTION

quency pulse while they are aligned by a powerful

magnet. In imaging the nuclei are usually seen as
protons in water or fat. The received signal is a
function of the number of protons present within the
localised volume, modified by the rate at which the
protons can give out energy after resonance by two
processes known as T, and T, relaxation. These
relaxation times are influenced by the quantity of
water and type and quantity of macromolecules in
the cell and so reflect oedema, type of tissue and
disease state but, unfortunately, in a non-specific and.
therefore, non-diagnostic way. Images giving good
anatomical detail can be obtained with a T, weighting
which can be achieved using the saturation recovery
technique or a spin-echo sequence with a short repetition time.3
Thin slices are advantageous and definition is
improved because the amount of overlap between
structures lying obliquely through the slice is reduced
and the edges become more distinct. Unfortunately
the thinner the slice the greater the noise on the
scan, increasing the signal : noise ratio and degrading
the final image. After removal of wisdom teeth, the
swelling contains fluid which, because of the high
water content, should be able to provide an accurate,
measurable image of tissue distortion around the
site.
The aim of this study was to assess the suitability
and accuracy of magnetic resonance imaging (MRI )
scans for measuring the swelling of the face and
lingual tissues after the removal of third molar teeth.

Patients undergoing third molar surgery commonly

have both pain and swelling in the operative area,
and MacGregor and Hart found that patients ability
to tolerate pain was associated with the amount of
swelling. Quantitative measurement of the swelling
is, however, difficult, inaccurate, and operator dependent, but it has important implications for assessing
the efficacy of drug regimens designed to reduce both
swelling and pain.
Holland reviewed available methods including
stereophotography,
ultrasonography
and various
mechanical devices. He emphasised that any method
used should be accurate, measurement should be in
volume units, and it should be both practical and
ethical, and not limited by static apparatus.
Recent work using computer digitisation of a standardised video frame has shown a greater accuracy
in recordings (less than 5% error) than has previously
been available (Cronin AJ, Walker R, Personal
Communication).
There has previously been an attempt to assess
volumetric changes from the lateral surface of the
mandible, but no attempt has been made, to our
knowledge, to measure the swelling produced on the
lingual side of the bone.
Magnetic resonance imaging
Magnetic resonance is a method of interrogating
nuclear spin by irradiating the nuclei with a radiofre419

420

British

PATIENTS

Journal

of Oral

and Maxillofacial

Surgery

AND METHODS

All patients gave informed consent.

Five patients aged 19-22 years old were studied,
who were to have bilateral removal of mesioangular
wisdom teeth, not covered completely in bone. Both
teeth looked alike with similar surrounding structures.
A scan was done before the operation which was
then carried out under general anaesthetic, both sides
being done by a single operator using a high speed
drill as advocated by Moore.4
A mucoperiosteal flap was raised distally, lingually
and buccally to the second molar tooth. After the
insertion of retractors both buccally and lingually, an
anterior cut was made into the bone buccally distal
to the second molar tooth with a Toller fissure burr.
The burr was moved distally and horizontally, curving
around the crown of the buried tooth, moving lingually and through the plate. The divided bone was
removed and the tooth elevated. The cavity was
rinsed with one wash of saline, and the wound closed
with two polyglactin 910 sutures (Vicryl, Ethicon).
Patients were discharged the following day after
another scan had been taken and the final scan was
done at the review appointment 7 days later.
Each patient was examined in a 1 Tesla Siemens
42SPE imager using a circularly polarised head coil.
From a T,-weighted midline sagittal localiser 20
contiguous transverse slices 5 mm thick were placed
over the mandibular area. A T,-weighted (SE600/15)
scan and a double echo proton density/T,-weighted
scan (SE2200/13 and 80) were taken with a field of
view of 230 mm and a 192 x 256 matrix. The data
were transferred to a SUN workstation where it was
analysed with the software package ANALYZE
(Mayo Foundation, Rochester, USA).
Measurement was made with the caliper tool in
the software package by the main examiner. Field of
view settings were altered to obtain the clearest anatomical delineation which resulted in changing. the
pixel dimension. Each patient was standardised for
the three scans. Several measurement lines were tried,
but the most consistent were those shown in Figure 1.
STATISTICAL

ANALYSIS

The preoperative scan for case 1 was used to calculate

the accuracy and reproducibility of readings by the
main examiner and a second examiner.
Readings along each of the lines (BB to EE) for
the buccal and lingual recordings were made with a
10 min interval between them.
Five readings were made at each point for the right
and left side of the scan. Therefore, each examiner
carried out 80 readings.
RESULTS

Tables 1 and 2 show the results of the two examiners.

The coefficient of variation for both was low,
although greater for the lingual readings than the
buccal ones. The mean coefficient of variation for

Fig. 1 - Line drawing of a sagittal MRI scan showing the

measurement lines used. AA is a midline drawn from between the
lower central incisors through the midpoint of the foramen
magnum. The next four lines were drawn perpendicular to this
line. BB: distal to the second premolar (called Premolar), CC:
distal to the first molar (Molar), DD: distal to the second molar
(Retromolar), EE: distal to the mandibular ramus (Ramus). The
measurement of buccal swelling was from the midline to the body
surface, and that of lingual swelling was from the midline to the
lateral border of the tongue.

examiner 1 was 1.9 15. There was no significant difference between the two examiners (P=O.679).
Figures 2, 3 and 4 show typical scans taken preoperatively and on the first and seventh days
postoperatively.
The initial scan was used as the control, and its
measurements subtracted from the postoperative
scans to obtain measurements of true swelling. Tables
3 and 4 show the mean, SD, SEM, and P values
using repeated measures analysis of variance and the
Tukey-Kramer
multiple comparisons test available
on Instat (Version 2.0, GraphPad Software, San
Diego, USA).
Figure 5 shows, in graphic form, the mean swelling
at the different positions.
A minus value for swelling was recorded lingually
because the swelling caused the tongue border to
become closer to the midline resulting in smaller
measurements in the second and third scans.
Subtraction from the first scan therefore produced a
minus value.
DISCUSSION

Over the years there have been several attempts to

objectively measure swelling after removal of wisdom

Use of MRI
Table

1 - Examiner

1 measurements

Region
Site

on MRI

Buccal
42.18
0.711
I .68

Mean
SD
Coefficient
of
variation
Mean coefficient

measurements
42.43
0.491
1.16

of variation:
Lingual
15.51
0.399
2.57

Mean
SD
Coefficient
of
variation
Mean coefficient

measurements
15.94
0.289
1.81

2 measurements

Region
Site:

Premolar

on MRI

measurements
43.26
0.629
1.45

Region
Postoperative

measured

with

51.41
0.782
1.52

51.28
0.948
1.85

51.73
0.821
1.42

58.24
0.662
1.14

56.76
0.95
1.67

57.18
0.803
1.4

17.82
0.661
3.71

19.02
0.575
3.02

19.85
0.772
3.89

20.3
0.482
2.38

39.58
0.118
0.3

41.2
0.468
1.14

n = 5 in all groups
Ramus

51.0
0.521
1.02

52.61
0.419
0.8

57.35
0.917
1.6

59.01
0.752
1.27

55.32
1.02
1.83

57.87
0.925
1.6

18.23
0.464
2.55

19.53
0.218
1.12

20.54
0.777
3.78

20.39
0.849
4.16

38.17
0.412
1 .Oh

40.34
0.676
1.68

(mm);

of freedom

P=O.679

n = 10 in all groups
Molar

7th

8.352
5.069
1.603
5.631

1st

2.721
3.406
1.077

4.934
3.425
1.083

4.025
3.862
>0.05

5.403

Tukey-Kramer

Multiple

4 - Lingual

swelling

<O.Ol
Comparison

Test:

measured

on MRI

Retromolar

Ramus

If the value

(mm):

of q is greater

7th

1st

0.909
2.665
0.843

5.356
4.039

7th
2.728
1.591

1st
2.271
3.234

7th
-1.172
2.461

1.277
0.503
1.023
2.628
3.443
2.522
3.304
>0.05
>0.05
than 4.437 then the P value is less than 0.05 (i.e. significant)

0.778

n = 10 in all groups

Premolar

Molar

Retromolar

Ramus

day
1st

Mean
SD
SEM
Mean difference
q
P value
TukeyyKramer

Retromolar

Premolar

difference

Region
Postoperative

Ramus

day

q
P value

Table

421

30 degrees

on MRI

1st
Mean
SD
SEM
Mean

teeth

I .4
measurements
16.47
0.625
3.79

Mean
SD
Coefficient
of
variation
Mean coefficient
of variation:
2.75
Comparing
examiner
1 and 2: t =0.417

swelling

molar

(mm);

of variation:

3 - Buccal

Retromolar

Molar

Lingual
16.09
0.616
3.83

of third

2.35

Table 2 - Examiner

Buccal
42.35
0.694
1.64

the removal

1.48

of variation:

Mean
SD
Coefficient
of
variation
Mean coefficient

after

n = 5 in all groups
Molar

Premolar
R

Table

(mm);

to assess swelling

Multiple

- 1.213
2.836
0.897
-0.243
0.247
> 0.05
Comparison

Test:

7th

1st

7th

- 0.970
3.608
1.141

- 0.268
2.396
0.757
0.748
0.762
> 0.05
of q is greater

-1.016
2.221
0.702

If the value

teeth. All required complex machinery and all were

limited by the inability to reproduce recording points.
In the evaluation of pain killing drugs, particularly
non-steroidal preparations that rely on reduction of

than

1st
0.480
2.653
0.838
0.838
0.853
>0.05
4.437 then the P value

7th
-0.358
2.124
0.672

is less than

1st

7th

0.740
~ 1.161
4.485
3.763
1.418
1.190
0.901
0.918
> 0.05
0.05 (i.e. significant)

swelling for their effectiveness, a reproducible, noninvasive technique for measuring swelling would be
extremely useful.
Even in objective recordings examiner variability

422

British

Journal

of Oral

and Maxillofacial

Surgery

Fig. 2 -A sagittal MRI scan taken through the cervical margins of the mandibular teeth preoperatively (scan 1).
Fig. 3 -A sagittal MRI scan taken on the first day postoperatively (scan 2).
Fig. 4 -A sagittal MRI scan taken on the seventh day postoperatively (scan 3).

Use of MRI

to assess swelling

after

the removal

of third

molar

teeth

423

Mean swelling (mm)

10
n

LinguaNlat

day PO)

Lingual(7th

day PO:

-2-y

Fig. 5 -The

mean

I
I
Molar
Retromolar
Measurement position

I
Premolar
swelling

(mm)

found

buccally

and lingually

in various

is common. Previous experiments5 have indicated an

8% variability for a single examiner. In our study the
variation between and within examiners was so low
as to have minimal effect on the readings and shows
the accuracy and reproducibility of the software.
The clinical results show that swelling on the buccal
side is certainly recordable and reproducible using
MRI. Lingual swelling did occur, but was not significantly different from preoperative scanning. The
problem was defining the lateral border of the tongue
with any accuracy.
MRI is a non-invasive technique but unless there
is a machine available for research, it is expensive.
Patients disliked the second and third scans because
they took 45 min to carry out and were claustrophobic, particularly the day after a general anaesthetic.
In conclusion the results are objective, showing a
mean swelling the day after operation of almost 1 cm,
This method would be useful in judging the efficacy
of steroids and non-steroidal anti-inflammatory drugs
after extraction of wisdom teeth.

References
1. MacGregor
AJ, Hart P. Effect of bacteria and other factors on
pain and swelling after removal
of ectopic mandibular
third
molars. J Oral Surg 1969; 27: 1744179.
2. Holland
CS. The development
of a method of assessing swelling

regions

on the first and seventh

I
Ramus
days postoperatively

(PO).

following
third molar surgery. Br J Oral Surg 1979; 17:
104-l 14.
3. Lloyd GAS. The Sinuses. In: Sutton D (ed). A textbook
of
radiology
and imaging. 5th Ed. Edinburgh:
Churchill
Livings&e,
1993:-p. 1257.
4. Moore JR. Princioles
of Oral Sureerv.
- , 1st Ed. Oxford:
Pergamon,
1965.
5. Llewelyn
J, Addy M. A photographic
method for the
assessment
of examiner
accuracy
and variability
for the scoring
criteria of the debris index. J Periodontol
1979; 50: 84489.

The Authors
John Llewelyn
FDSRCS,
FRCS
Consultant
Department
of Maxillofdcial
and Oral
Royal Gwent Hospital
Cardiff Road
Newport
Gwent NP9 2UB, UK
Martin Ryan FDSRCS,
FRCS
Registrar
Department
of Maxillofacial
Surgery
The City Hospital
Edinburgh,
UK
Celestine Santosh MD, FRCR
Lecturer
University
Department
of Radiology
University
of Edinburgh
Edinburgh,
UK
Correspondence

and requests

Paper received 18 May 1994

Accepted
8 August 1995

Surgery

for offprints

to Mr J. Llewelyn