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J Oral Maxillofac Surg

70:2327-2332, 2012

Evaluation of the Inferior Alveolar Canal


for Cysts and Tumors of the Mandible
Comparison of Multidetector Computed
Tomography and 3-Dimensional Volume
Interpolated Breath-Hold Examination
Magnetic Resonance Sequence
With Curved Multiplanar
Reformatted Reconstructions
K. Srinivasan, MD,* Ashu Seith, MD,
Ankur Gadodia, MD, DNB, Raju Sharma, MD, MNAMS,
Atin Kumar, MD, DNB, Ajoy Roychoudhury, MDS, and
Ongkila Bhutia, MDS#
Objective: To evaluate the mandibular canal using volume interpolated breath-hold examination (VIBE)
sequencing in patients with cysts and tumors of the mandible.
Materials and Methods: Twenty-five patients with mandibular cysts and tumors were recruited for a study in
the authors institution to compare the role of multidetector row computed tomography with magnetic resonance
imaging (MRI) in jaw lesions. Of these 25 patients, VIBE was performed in 12 patients (age range, 16 to 52 yrs; 11
male and 1 female patients) and formed the study group. The status (normal/destroyed/attenuated) and position of
the inferior alveolar canal (normal/displaced) on panoramic reconstructed computed tomographic (CT) images
and curved multiplanar reformatted (MPR) images reconstructed from VIBE images were analyzed. The contralateral normal mandibular canal was used as the control in these patients.
Results: In all 12 patients, the inferior alveolar canal on the normal side was visualized as a hyperintense structure in relation to the hypointense bone on the curved MPR VIBE images. In 9 patients, the
inferior alveolar canal was equally well visualized on panoramic CT and curved MPR VIBE images. In 2
patients, the inferior alveolar canal was better visualized on curved MPR VIBE images; in 1 patient, the
course of the mandibular canal was better seen on panoramic CT images.
Conclusions: MR reconstructions with VIBE sequencing as source images provide images comparable to CT
reconstructed images for evaluation of the mandibular canal. Three-dimensional (3D) VIBE sequencing can be
added to the MR protocol to visualize the inferior alveolar neurovascular bundle. 3D VIBE sequencing increases the
diagnostic capabilities of MRI when used to image mandibular cysts and tumors.
2012 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 70:2327-2332, 2012

Received from the All India Institute of Medical Sciences, New


Delhi, India.
*Senior resident, Department of Radiodiagnosis.
Additional Professor, Department of Radiodiagnosis.
Senior resident, Department of Radiodiagnosis.
Professor, Department of Radiodiagnosis.
Associate Professor, Department of Radiodiagnosis.
Additional Professor, Department of Oral and Maxillofacial Surgery.

#Associate professor, Department of Oral and Maxillofacial Surgery.


Address correspondence and reprint requests to Dr Seith: Department of Radiodiagnosis, All India Institute of Medical Sciences,
New Delhi, India 110029. e-mail: ashubhalla1@yahoo.com
2012 American Association of Oral and Maxillofacial Surgeons

0278-2391/12/7010-0$36.00/0
doi:10.1016/j.joms.2011.10.026

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The inferior alveolar canal (mandibular canal) is an
important surgical landmark that should be assessed preoperatively in patients with tumors and
cysts arising from the body and ramus of the mandible to avoid injury to the neurovascular bundle.
The inferior alveolar nerve and vessels enter the
mandibular foramen on the medial surface of the
ramus, traverse through the mandibular canal anteroinferiorly, and exit through the mental foramen.1 Multidetector row computed tomography
(MDCT) enables rapid thin-section acquisition of
the regional body anatomy. The course of the bony
mandibular canal is best visualized on axial and
panoramic reconstructed images. However, in patients lacking a bony limitation of the mandibular
canal and to avoid radiation, magnetic resonance
imaging (MRI) can be performed to study the mandibular canal.2 In recent years, MRI has been increasingly used to evaluate cysts and tumors of the
oral and maxillofacial region. Volumetric interpolated
breath-hold examination (VIBE) is a rapid 3-dimensional (3D) gradient echo sequence with fat suppression.3 The integrated fat saturation helps visualize the
mandibular canal by suppressing the fatty bone marrow. The objective of this study was to evaluate the
mandibular canal using the VIBE sequence in patients
with cysts and tumors of the mandible.

Methods and Materials


Twenty-five patients with mandibular cysts and tumors were recruited for a study in the All India Institute of Medical Sciences (New Delhi, India) to compare the role of MDCT with MRI in jaw lesions. All
patients were included after obtaining informed consent, and the study was approved by the institutional
ethics committee. In a subset of 12 patients (age
range, 16 to 52 yrs; 11 male and 1 female patients), in
addition to the spin echo T1 and T2 sequences, VIBE
sequences were performed before and after intravenous administration of gadolinium. The VIBE sequence and its reconstruction were standardized during the course of the study; hence, this sequence was
performed in only a limited number of patients.
MDCT was performed using a Somatom Sensation
40-slice CT scanner (Siemens, Erlangen, Germany).
Axial sections were obtained at 0.6-mm intervals parallel to the alveolar ridge. Panoramic reconstruction
was performed from these axial images using integrated dental imaging software. syngo Dental CT (Siemens, Muenchen, Germany).
MRI of the mandible was performed on a 1.5-T MR
scanner (Avanto; Siemens) using a head coil. The
protocol for MRI included a T1 sequence (repetition
time, 600 to 800 ms; echo time, 17 ms) and a T2

MANDIBULAR CYSTS AND TUMORS

sequence (repetition time, 3,000 to 4,000 ms; echo


time, 70 to 90 ms). The section thickness varied from
3 to 5 mm with matrix of 256 256. The parameters
used for the VIBE sequence were a repetition time of
5.5 ms, an echo time of 2.5 ms, a flip angle of 10, a
field of view of 160 cm, a matrix of 256 256, a
section thickness of 1 mm, and an acquisition time of
55 seconds. The patients were not instructed to hold
their breath because artifacts related to respiratory
motion are minimal in the head and neck region, but
they were required to avoid swallowing (breath-hold
acquisition, ie, scanning the entire anatomic region in
a single breath-hold is commonly performed in abdominal imaging). After gadolinium administration,
axial images obtained from the VIBE sequence were
reconstructed using curved multiplanar reformatting
(MPR). Curved MPR is a view mode commonly used
for visualizing structures with a curved geometry such
as the mandible. It is obtained by drawing a curved
line over visible parts of the mandibular canal on the
axial images and then reconstructed using postprocessing software.
The panoramic images obtained from the reconstructions were analyzed by consensus by 2 radiologists (A.S. and R.S.) with 10 and 15 years of experience, respectively, in CT and MRI. Images from CT
and MRI were analyzed in separate viewing sessions
that were separated by at least 1 month. The parameters used for analysis were the status (normal/destroyed/attenuated) and position (normal/displaced)
of the mandibular canal. The contralateral normal
mandibular canal was used as the control in these
patients.
On MDCT images, the canal was labeled normal if
the cortical wall of the mandibular canal was visualized in its full extent. The canal was labeled destroyed
if the entire or a portion of the canal was not visualized or if the cortical wall of the canal was disrupted.
On MR images, the inferior alveolar canal was labeled
normal if the neurovascular bundle was visualized as
a hyperintense structure in its entire extent. The inferior alveolar canal was considered destroyed if the
neurovascular bundle was not visualized in the region
of the tumor or attenuated if the neurovascular bundle was seen as a thin hyperintense structure coursing
through the tumor. The position of the canal/neurovascular bundle was also assessed on MDCT and MR
images and categorized as normal or displaced.
A scoring system was used for the status and position of the inferior alveolar canal on panoramic reconstructed CT images and curved MPR images reconstructed from VIBE sequences. A score of 1 indicated
that the 2 images were similar, 2 indicated that the CT
panoramic image was better than the curved MPR
VIBE images, and 3 indicated that the curved MPR
VIBE image was better than the CT panoramic image.

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SRINIVASAN ET AL

Table 1. COMPARISON OF MULTIDETECTOR ROW COMPUTED TOMOGRAPHY WITH MAGNETIC RESONANCE


IMAGING IN ALL PATIENTS

Subject
Number

Location of Lesion

MDCT Panoramic
Reconstruction

Right ramus and body

2
3
4

Midline of body
Left ramus
Left ramus and body

5
6

Right ramus and body


Right ramus and body

Left body

Right body

Destroyed and
displaced
Destroyed
Entire length seen
Inferiorly displaced and
destroyed
Destroyed
Destroyed and
inferiorly displaced
Destroyed and
inferiorly displaced
Distal canal not seen

Right ramus

10
11

Midline of body
Left body

12

Right ramus and body

Curved MPR VIBE Images

Score

Histopathology

Attenuated and displaced

Giant cell granuloma

1
2
1

Ameloblastoma
Ameloblastoma
OKC

1
1

Ameloblastoma
OKC

Giant cell granuloma

Ameloblastoma

Destroyed

Destroyed
Not seen
Inferiorly displaced and
destroyed
Destroyed
Destroyed and inferiorly
displaced
Destroyed and inferiorly
displaced
Entire course seen with distal
part destroyed
Destroyed

Normal
Destroyed and
inferiorly displaced
Destroyed and
inferiorly displaced

Normal
Destroyed and inferiorly
displaced
Destroyed and inferiorly
displaced

1
1

Aneurysmal bone
cyst
OKC
Giant cell granuloma

Ameloblastoma

Abbreviations: MDCT, multidetector row computed tomographic; MPR, multiplanar reformatting; OKC, odontogenic keratocyst; VIBE, volume interpolated breath-hold examination.
Srinivasan et al. Mandibular Cysts and Tumors. J Oral Maxillofac Surg 2012.

Results
This study included 12 patients with mandibular cysts
and tumors; 5 patients had ameloblastoma, 3 patients
each had odontogenic keratocyst and giant cell reparative granuloma, and 1 patient had aneurysmal bone cyst.
In all 12 patients, the inferior alveolar canal on the
normal side was visualized as a hyperintense structure in
relation to the hypointense bone on the curved MPR
VIBE images. The vessels and nerve within the canal
were not visualized separately. On panoramic CT images, the mandibular canal was visualized as a lucent
band outlined by 2 hyperdense lines representing the
cortical walls of the canal. The curved MPR VIBE images
were compared with the panoramic images reconstructed
from axial CT images (Table 1).
In 9 patients, the inferior alveolar canal was equally
well visualized on the panoramic CT and curved MPR
VIBE images (score 1; Fig 1). On these images, the
canal was destroyed in 3 patients (cases 2, 5, and 9),
inferiorly displaced and destroyed in 5 patients (cases
4, 6, 7, 11, and 12), and normal in 1 patient (case 6).
In 1 patient (case 3; Fig 2), the course of the
mandibular canal was better visualized on the panoramic CT image (score 2). The neurovascular bundle
was not visualized on MRI because the tumor was also
hyperintense, thus obscuring the nerve coursing
through the tumor. However, the course of the canal
through the tumor was well visualized on the CT

image because its cortical walls were preserved. This


was a case of ameloblastoma.
In 2 patients, the inferior alveolar canal was better
visualized on the curved MPR VIBE image (score 3).
Of these 2 patients, 1 patient (case 8; Fig 3) lacked the
cortical wall of the distal mandibular canal on the 2
sides on the CT image owing to osteoporosis, which
was confirmed by a correlation with the sagittal and
coronal images. The MR image visualized the entire
course of the neurovascular bundle. In the other patient (case 1), the attenuated and displaced neurovascular bundle was better visualized on the curved MPR
VIBE image than on the CT image.

Discussion
VIBE is an ultrafast gradient echo sequence that
uses a T1-weighted 3D sequence with integrated fat
saturation.3 This sequence uses thin sections of about
1 to 3 mm, resulting in an isotropic spatial resolution.
VIBE was initially used in abdominal imaging because it can acquire the dataset in a single breathhold, thus decreasing the artifacts limited by respiratory motion.4 The integrated fat saturation improves
the contrast-to-noise ratio and the detection of vascular structures on images after gadolinium administration and thus also has a role in MR angiography. VIBE
uses a short repetition time (range, 3 to 5 ms) and

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MANDIBULAR CYSTS AND TUMORS

FIGURE 1. Case 10: Odontogenic keratocyst in a 22-year-old man. A, Panoramic reconstructed computed tomographic image shows a
unilocular lytic lesion in the midline and the 2 mandibular canals are normal. B, Curved multiplanar reformatted volume interpolated
breath-hold examination image after gadolinium administration shows a unilocular cystic lesion and a normal hyperintense neurovascular
bundle on either side. A score of 1 was given for this case.
Srinivasan et al. Mandibular Cysts and Tumors. J Oral Maxillofac Surg 2012.

lacks phase artifacts. The integrated fat saturation on


VIBE sequences makes it suitable for whole-body
screening for metastases.3 Kataoka et al5 evaluated
the role of contrast-enhanced VIBE in 33 patients with
head and neck tumors. They found that VIBE images
were superior in resolution despite a decrease in
acquisition time with fewer artifacts compared with
the routine spin echo T1 sequence. They concluded
that VIBE can be used as an alternative for the postcontrast spin echo T1 sequence in the preoperative
assessment of head and neck tumors.
The preoperative assessment of the mandibular canal is important to determine the nature of the lesion,
and to decide the surgical management. Lesions
above the canal are likely to be odontogenic, whereas
lesions below it are usually nonodontogenic in nature.6 The surgical management of mandibular tumors
depends on the extent of infiltration of the surrounding soft tissues, involvement of the cortical bone, and
the inferior alveolar nerve. Williams7 suggested a
wide resection with a 2-cm margin of normal bone for
operating on mandibular bone tumors. When the tu-

mor is surrounded by the inferior alveolar nerve, it


should be resected en bloc with the nerve. However,
the patient will have permanent numbness of the
region innervated by the mental nerve. Thus, it is
useful to delineate the course of the inferior alveolar
nerve preoperatively using imaging.
MDCT helps in the excellent visualization and delineation of the inferior alveolar canal. It also helps to
assess the buccolingual position and height of the
neurovascular bundle. However, the effective radiation dose received by the tissues near the mandible
for a single MDCT examination ranges from 474 to
1,160 Sv.8,9 Many cadaveric studies have been conducted to validate the role of MRI as an alternative to
CT for evaluating the neurovascular bundle.10,11 All
these studies have shown that MRI can be used to
evaluate the mandibular canal compared with dental
CT images. Eggers et al12 in their cadaveric study
evaluated the geometric accuracy of MRI of the mandibular canal. They superimposed the coronal CT and
MR images, which were acquired with a similar resolution and field of view using Interactive Data Lan-

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SRINIVASAN ET AL

FIGURE 2. Case 3: Ameloblastoma in a 42-year-old man. A, Panoramic reconstructed multidetector row computed tomographic image
shows the attenuated left mandibular canal (arrowhead) coursing through the tumor. B, Curved multiplanar reformatted volume interpolated
breath-hold examination image shows nonvisualization of the left proximal inferior alveolar canal through the hyperintense lesion (asterisk)
in the left ramus, with the distal part visualized. A score of 2 was given for this case.
Srinivasan et al. Mandibular Cysts and Tumors. J Oral Maxillofac Surg 2012.

guage software (IDL; Research Systems Inc., Boulder,


CO) and found an excellent concordance of the mandibular nerve on MR images and the mandibular canal
on CT image data. They recommended a VIBE sequence with a flip angle of 15 for optimal visualization of the mandibular canal.
To the best of the authors knowledge, there is only
1 in vivo study that has evaluated the role of highresolution gradient echo sequencing (with a spectral
fat suppression preimpulse) in 11 patients with dysesthesia in the floor of the mouth to visualize the
mandibular canal.13 MR images were acquired in the
axial plane, and coronal and panoramic reconstructions were performed subsequently using dental software. They concluded that dental MRI could become
a viable alternative to 3D MPR CT programs.
In the present study, the role of curved MPR using
3D VIBE sequencing to visualize the mandibular canal
was evaluated in patients with cysts and tumors of the
mandible. Because the VIBE is an ultrafast gradient
echo sequence with fat suppression, the contrast between the neurovascular structures and the surrounding bone is very high owing to suppression of the

fatty bone marrow. The curved MPR reconstructed


image from the VIBE sequence clearly visualized the
neurovascular bundle, whether it was normal, destroyed, or attenuated. MRI has a distinct advantage
over CT in patients who lack the cortical wall of the
mandibular canal because of osteoporosis or destruction by tumor, as seen in 2 cases in the present study,
where MR clearly visualized the mandibular canal.
However, when the tumor has the same intensity as
that of the neurovascular bundle, then it becomes
difficult to trace it through the tumor, as seen in 1
case in the present study. The limitation of the present study was the small number of patients.
Thus, the VIBE sequence with curved MPR reconstructions can provide an alternative to panoramic
MDCT images in the evaluation of the mandibular canal.
Assessment of the mandibular canal is also important in
the preoperative assessment of dental implant placement. However, a larger study is required to evaluate the
geometric accuracy of this sequence.
To conclude, MR reconstructions with VIBE sequences as source images provide images comparable to
CT reconstructed images for evaluation of the mandib-

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MANDIBULAR CYSTS AND TUMORS

FIGURE 3. Case 8: Ameloblastoma in a 42-year-old man. A, Panoramic reconstructed multidetector row computed tomographic image
shows a multilocular lesion in the body of the right hemimandible with the nonvisualized distal mandibular canals on the 2 sides (arrowheads)
because of extensive osteoporosis. B, Curved multiplanar reformatted volume interpolated breath-hold examination image after gadolinium
administration shows a hyperintense lesion (asterisk) in the right hemimandible with destruction of the distal right canal (arrow). The left
inferior alveolar canal was normal. A score of 3 was given for this case.
Srinivasan et al. Mandibular Cysts and Tumors. J Oral Maxillofac Surg 2012.

ular canal. Hence, when MRI is performed in patients


with cysts and tumors of the mandible to visualize soft
tissue extension or in patients with contraindications to
MDCT, the 3D VIBE sequence can be added to the MRI
protocol to visualize the inferior alveolar neurovascular
bundle. The 3D VIBE sequence can increase the diagnostic capabilities of MRI when used to visualize mandibular cysts and tumors.

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