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DOI 10.1007/s11282-017-0274-z
REVIEW ARTICLE
Abstract The basic principles and diagnostic methods of Keywords Diagnosis Magnetic resonance imaging
magnetic resonance imaging (MRI) for beginning surgeons Maxillofacial
are described in this review. MRI is an important technique
that is essential for diagnoses in the maxillofacial area. It
is a scanning method that obtains tomographic images of Introduction
the human body using a magnetic field. In contrast to com-
puted tomography, it does not utilize X-rays and, therefore, Magnetic resonance imaging (MRI) began with the dis-
represents a noninvasive test that lacks radiation expo- covery of nuclear magnetic resonance by Bloch [1], fol-
sure. It is particularly effective for soft-tissue diagnoses. lowed by the worlds first imaging using nuclear magnetic
MRI involves imaging protons invivo. Protons emit a sig- resonance by Lauterbur [2]. At present, MRI and computed
nal when a radio frequency pulse is applied in a magnetic tomography (CT) are essential techniques in modern medi-
field; the MRI device then forms an image from these sig- cine. MRI is an important testing method essential for diag-
nals. The basic images produced are T1- and T2-weighted noses in the maxillofacial area. This technique utilizes a
images; comparison of these images is the first step of magnetic field to obtain tomographic images of the human
MRI-based diagnosis. Short-T1 inversion recovery images, body. In contrast with CT, MRI does not utilize X-rays and
which eliminate the signal from fat, are also useful for is, therefore, a noninvasive test that lacks radiation expo-
diagnosis. Gadolinium is used as a contrast agent for MRI. sure. It is particularly effective for soft-tissue diagnoses,
Taking sequential images at fixed intervals while inject- even in the oral cavity, including benign and malignant
ing the contrast agent and then graphing the contrast effect neoplasms, inflammation, and temporomandibular joint
along the time axis produces a timesignal intensity curve, disorders. This review describes the basic principles and
which is useful for identifying features such as malignant diagnostic methods of MRI for beginner oral and maxillo-
neoplasms based on the graph pattern. facial radiologists.
MRI machines
* Toyohiro Kagawa MRI machines are based on the same principle as are
kagawat1@college.fdcnet.ac.jp electromagnets, which produce a magnetic field by pass-
1 ing an electrical current through a massive coil. To elimi-
Section ofImage Diagnosis, Department ofDiagnostics
andGeneral Care, Fukuoka Dental College, 2151 Tamura, nate electrical resistance, the coil is enveloped by liquid
Sawaraku, Fukuoka8140193, Japan helium (273C) to bring it into a superconducting state.
2
Department ofRadiology, Fukuoka Dental College Medical The strength of the magnetic field of the superconduct-
andDental Hospital, Fukuoka, Japan ing magnets in mainstream MRI machines today is 1.5 or
3
Section ofRemovable Prosthodontics, Department ofOral 3.0 T (T; a unit quantifying magnetic field density). The
Rehabilitation, Fukuoka Dental College, Fukuoka, Japan type of superconducting magnet used in MRI machines
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Fig.3Conceptual diagram of obtaining signals from protons in tons become deflected by 90. The deflected protons then continue to
the body. a Protons are generally oriented in a variety of directions store the energy of the RF pulse. d If the RF pulse is suspended, the
within the body. b When entering a powerful magnetic field, they deflected protons return to their previous orientation while emitting
change from having a scattered orientation to being aligned within their stored energy. e After the scan, when exiting the MRI machine,
the magnetic field. c If an RF pulse is applied in this state, the pro- the protons become reoriented in scattered directions within the body
these tissues contain many hydrogen atoms. MRI machines (Fig.3b). If a radio frequency (RF) pulse is applied in this
produce images based on the nuclei of these hydrogen state, the protons become deflected by 90 (Fig. 3c). This
atoms (also known as protons). The hydrogen nuclei have a phenomenon is known as nuclear magnetic resonance.
magnetic field; therefore, they can each be considered as a When the RF pulse is applied, a large sound unique to the
tiny magnet (Fig.2). MRI scan is emitted. The deflected protons then continue
Protons are generally oriented in a variety of direc- to store the energy of the RF pulse. If the RF pulse is sus-
tions within the body (Fig.3a). However, when entering a pended, the deflected protons return to their previous ori-
powerful magnetic field, they change from having a scat- entation while emitting their stored energy. The duration
tered orientation to being aligned within the magnetic field of this return differs depending on the type of tissue (mus-
cle, blood, fat, etc.) in which the protons are bonded. This
energy is received by a receiver as a signal, and an image
is formed by analyzing this signal and the time duration of
the return (Fig.3d). After the scan, when exiting the MRI
machine, the protons become reoriented in scattered direc-
tions within the body (Fig.3e).
Fig.4Computed tomography (CT) and magnetic resonance imaging MRI artifacts caused bymetal
(MRI) of the same slice. MRI has a lower spatial resolution than CT;
therefore, tissue boundaries are difficult to ascertain. In contrast, MRI
Because MRI examinations utilize a magnetic field, arti-
has a high ability to resolve tissues. While CT scans do not indicate
density differences among tissues, the differences in density among facts can occur due to the presence of magnetic metals in
tissues are clear in MRI scans the imaging area. Even if the magnetic metals themselves
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Fig.5Conception diagram of a metal artifact. Artifacts caused by metals in computed tomography scans appear only within slices, but they
appear in three-dimensional directions in magnetic resonance imaging scans
Fig.6Proton phase and vector quantity. When deflected protons vector quantity in the longitudinal direction is known as the T1 value,
revert to their original states, the longitudinal and transverse vector and that required for recovery of the vector quantity in the transverse
quantities change. The duration of time required for recovery of the direction is the T2 value
do not exhibit magnetism, they become magnets in the quantity in the transverse direction is the T2 value (Fig.6).
magnetic field. As a result, they form their own magnetic Graphs of vector quantity changes in the longitudinal and
fields that cause the local magnetic field to become nonu- transverse directions over time are called the T1 curve and
niform. Therefore, while artifacts only appear in the direc- T2 curve, respectively (Fig. 7). Changes in these vector
tion of slices in CT scans, they appear as three-dimensional quantities over time vary according to the type of tissue.
missing signals in MRI examinations (Fig.5). T1-weighted images (T1WI) represent tissues with a higher
signal of the shorter T1 value (short longitudinal relaxa-
tion time and rapid signal recovery). T2-weighted images
Basic MRI images (T2WI) represent tissues with a higher signal of the longer
T2 value (long transverse relaxation time and slow signal
T1 andT2weighted images attenuation). T1WI and T2WI signals in normal tissue are
shown in Table1.
As explained earlier, protons in the body are deflected by
an RF pulse in the magnetic field of an MRI device. When Diagnoses using T1WI andT2WI
the RF field is removed, the protons return to their origi-
nal state. The duration of time required to return to the vec- T1WI and T2WI are the basic images used for MRI diagno-
tor quantity in the longitudinal direction is known as the ses, the first step of which is comparison of the two images.
T1 value, and the time required to attenuate to the vector Some basic cases are shown in Figs. 8 and 9. Figure 8
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Fatsuppression images
Contrastenhanced MRI
Table1Magnetic resonance imaging signals of normal tissue
A gadolinium preparation is used as the contrast agent in
T1WI T2WI MRI; typically, 0.2 ml/kg is administered intravenously.
Gadolinium has a high T1-shortening effect and is, there-
High intensity Fat Fat
(light gray) Bone marrow (adult) Water fore, used as a contrast agent to increase the diagnostic abil-
Bone ity [9, 10]. The gadolinium contrast agent has an adverse
marrow effect rate of approximately 12% and is thus considered
(adult)
safer than iodine contrast agents. However, it is contraindi-
Bone
marrow cated for asthmatic patients. In addition, caution is required
(child) because of the risk of nephrogenic systemic fibrosis in
Low intensity Water Muscle patients with severe renal impairment [11, 12].
(dark gray) Muscle Capturing sequential images at fixed intervals while
Bone marrow (child)
injecting the contrast agent and then graphing the contrast
No signal intensity Cortical bonecalcium deposition
effect along the time axis produces a timesignal intensity
(black) Enameldentin
Airblood vessel curve (TIC). This curve is useful for identifying features
such as malignant neoplasms based on the graph pattern
Signal values differ in each type of tissue depending on the amount of [1317]. The main lesions and TIC patterns are shown in
protons present. Understanding the T1-weighted image (T1WI) and
T2-weighted image (T2WI) signal values (image density) in normal
Fig.11.
tissue is important for achieving correct diagnoses. Because the bone Figure12 shows a 21-year-old man who presented with
marrow signal differs between children and adults and blood vessels the chief complaint of swelling in the floor of the mouth.
do not produce a signal, caution is required for interpretation, espe- Even after some time had elapsed, the contrast agent did
cially with T1WI
not enter the lesion. The TIC exhibited a plateau shape, and
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Fig.8Magnetic resonance
imaging of a lipoma. The
lesion in the right cheek is
depicted as a high signal in both
T1-weighted and T2-weighted
images; therefore, the contents
can be diagnosed as fatty tissue
Fig.9Magnetic resonance
imaging of a ranula. The lesion
in the left submandibular region
is depicted as having a low
signal in T1-weighted images
and high signal in T2-weighted
images. Therefore, the contents
can be defined as water
Fig.10Magnetic resonance
imaging of inflammation in the
right cheek. In the T2-weighted
image, fatty tissue and water-
based tissue are both depicted as
having high signals. Therefore,
the range of inflammation is
difficult to determine. Because
short-TI inversion recovery
cancels the signal from fatty tis-
sue, the range of inflammation
is easy to ascertain
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Diffusionweighted image
Fig.12Timesignal intensity
curves of the ranula. Ranulas
have no internal blood flow;
therefore, contrast agent does
not flow into the lesion. The
timesignal intensity curve
consequently exhibits a plateau
shape
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Fig.13Timesignal intensity
curve of squamous cell carci-
noma. Squamous cell carcinoma
comprises tumor tissue with
significant blood flow inside;
therefore, the contrast agent
flows rapidly into the lesion.
Thereafter, the contrast agent
slowly flows out from the tumor.
The timesignal intensity curve
exhibits a sudden increase and
then a gradual decrease
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