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HEAD AND NECK IMAGING Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 3  |  Page : 379-384
Usefulness of dynamic maneuvers in MR evaluation of oral malignancies

Department of MRI, Rajiv Gandhi Cancer Institute & Research Centre, Sector-5, Rohini, New Delhi-110085, India

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Objectives : The purpose of this study was to evaluate the usefulness of dynamic maneuvers like "distended cheek" and "tongue deviation" in MR evaluation of oral malignancies. Methods : Ninety nine patients of oral malignancies who reported to this institute for treatment were enrolled in this study. All the patients evaluated with conventional MR imaging and supplemented by additional MR imaging with dynamic maneuvers using T1Weighted and STIR sequences with reduced scan time. Distended cheek imaging was performed in 73 cases of carcinoma cheek, gingiva & RMA (retromolar area) and tongue deviation in 24 cases of carcinoma tongue & floor of mouth. Two cases of carcinoma of lower gingiva performed both maneuvers. In selected cases MR imaging with dynamic maneuvers was also performed following contrast administration. Results : Lesions appearing inseparable from two mucosal surfaces (buccal mucosa and gingiva) on routine MR images were well separated in the distended cheek images in all cases except for two cases who could not perform the maneuvers. Distended cheek images demonstrated involvement of buccogingival sulci in 30 patients of carcinoma of cheek, involvement of cheek in 8 cases of carcinoma gingiva & involvement of gingiva in 6 cases of carcinoma cheek which were not appreciated on routine MR images. Similarly MR imaging with tongue deviation helped in better delineation of tongue lesions in 12 cases and showed involvement of glossogingival sulcus in 5 cases that were not appreciable on routine MR imaging. Conclusion : MR imaging with dynamic maneuvers provide additional information of clinical significance regarding origin and extent of disease in oral malignancies & should supplement the conventional MR imaging in selected cases.

Keywords: Oral malignancy, Magnetic resonance imaging

How to cite this article:
Oberoi R, Jena A. Usefulness of dynamic maneuvers in MR evaluation of oral malignancies. Indian J Radiol Imaging 2006;16:379-84

How to cite this URL:
Oberoi R, Jena A. Usefulness of dynamic maneuvers in MR evaluation of oral malignancies. Indian J Radiol Imaging [serial online] 2006 [cited 2020 Sep 22];16:379-84. Available from:

   Introduction Top

Magnetic resonance imagining has been shown to be a useful tool in the evaluation of oral malignancies because of direct visualization of lesion due to high soft tissue contrast and multiplanar capability [1]. Apposed mucosal surfaces of the oral cavity however in some cases pose difficulty in defining the origin and extent of the disease. In these cases dynamic maneuvers could help in providing useful information about the local extent of a tumor.

In recent reports it has been shown that dynamic maneuvers could improve CT evaluation in pathology of oral vestibule [2],[3]. In the present study we performed additional MR imaging with cheek distended with air to separate the gingiva from buccal mucosa and tongue deviation to separate tongue & floor of mouth from the gingiva to assess the usefulness of these maneuvers in improving MR evaluation. To the best of our knowledge no such study has been reported in the literature.

   Materials and Methods Top

MR imaging of oral cavity with dynamic maneuvers was performed in three volunteers as a pilot study to study the normal anatomy of oral vestibule.

Ninety nine patients (82 man & 17 women), of ages ranging between 27 to 76 years (mean age of 50.5 years) of biopsy proven oral malignancies underwent routine MR imaging followed by MR imaging with dynamic maneuvers before initiation of definitive treatment. A 1.0T MRI scanner was used to obtain images in all cases (Magentom Impact Expert Siemens, Germany). Cheek distension was performed in 73 cases of oral malignancies (46 cheek, 23 gingiva, 4 retromolar area) and tongue deviation towards contralateral side of lesion in 24 cases (22 carcinoma tongue & 2 carcinoma floor of mouth). Two cases of lower gingival carcinoma performed both maneuvers. Histological diagnosis was squamous cell carcinoma in 96 patients, adenocystic carcinoma in 1 patient & verrucous carcinoma in 2 patients.

The routine axial and coronal T1Weighted SE & STIR (short tau Inversion recovery) images with 5mm slice thickness & 0.1mm interslice gap were initially obtained through the oral cavity with the following scan parameters: (a) T1Weighted SE sequence: TR/TE 627/15 ms, matrix 120 x 256, number of slices 19, number of acquisitions two, scan time 2 min 33 sec & (b) STIR sequence: TR 4750ms, TE 14/85 ms, TI 140ms, matrix 120 x 256, number of slices 19, number of acquisitions two, scan time 3 min 54 sec.

Routine MR imaging is followed by MR imaging with dynamic maneuvers like cheek distension and/or tongue deviation towards contralateral side of lesion in all cases. To make the MR imaging with dynamic maneuvers, precise scanning location were chosen from the routine images & scanning time was reduced. T1Weighted & STIR images were taken in axial and coronal planes in all the cases and in sagittal plane in one case (midline lesion of lower alveolar gingiva). 5mm slice thickening and 0.1 mm interslice gap were taken in all cases with following scan parameters: (a) STIR images: TR 2800ms, TE 14/85ms, TI 140ms, matrix 120 x 256, number of slices 11, number of acquisition 1, scan time 1 min & (b) T1Weighted images: TR/TE 500/15 ms, matrix 120 x 256, number of slices 11, number of acquisition one, scan time 1min 15 sec. Post contrast T1Weighted imaging with dynamic maneuvers performed after intravenous injection of 0.1 mmol/kg of gadodiamide (Omniscan, Amersham Health, Cork, Ireland) in 13 cases (6 cases of gingival carcinoma and 7 cases of carcinoma cheek).

Two radiologists interpreted all the images in consensus for origin and extent of disease.

   Anatomy Top

The oral cavity is divided into an outer, smaller portion, the vestibule which lies between the lips and cheeks externally and the gums and teeth internally, and the oral cavity proper, which lies within the alveolar arches, gums and teeth [4]. Cheek forms the lateral wall of the vestibule made up of skin, superficial fascia, buccal fat, buccinator muscle, submucosa and the buccal mucosa which are well demonstrated on MR imaging. The buccal mucosa is reflected on the upper & lower alveolar ridges to form respectively the upper and lower buccogingival sulci. Normally the buccal mucosa remains apposed against the gingiva obliterating the buccogingival sulci. Posteriorly the mucosal reflection of vestibule connects with the oral cavity behind the last molar tooth & the mandibular retromolar trigone. Air in the oral cavity in a distended cheek distends the vestibule separating the apposed surfaces [Figure - 1]. The floor is formed largely by the anterior two third of the tongue & by the reflection of the mucous membrane to the mandibular gingiva forming glossogingival sulcus. A deviated tongue separates the tongue & floor of mouth from gingiva and exposes the ipsilateral glossogingival sulcus [Figure - 6]B.

   Results Top

The patient compliance was excellent expect for two patients who could not perform the cheek distention, in one patient due to orocutaneous fistula and other patient was edentulous.

MR images with dynamic maneuvers provided additional information over conventional MR images in all cases [Table - 1] Summarizes the additional information obtained with distended cheek MR imaging. Tumor location is better depicted in all the cases. Involvement of buccal mucosa & buccinator muscle is well seen. Distended cheek images showed involvement of buccogingival sulci in 30 cases [Figure - 2] which were not appreciated on routine MR images due to apposed mucosal surfaces. Involvement of gingiva was found in 6 cases of carcinoma cheek [Figure - 2] and involvement of cheek in 8 cases of gingival carcinoma. Lesion localised only to cheek in 17 cases [Figure - 3] and upper or lower buccogingival sulcus [Figure - 4] in 2 cases could be unequivocally demonstrated with distended cheek images that were difficult to assess in routine images. In tumors of retromolar trigone, these images also correctly showed involvement of cheek in one case and involvement of buccogingival sulcus in another two cases.

With the tongue deviated away from the gingiva towards contralateral side of the lesion allowed separation of tongue & floor of mouth from gingiva and helped in detecting involvement of glossogingival sulcus [Figure - 5] in 5 cases (2 tongue, 1 floor of mouth and 2 lower gingival carcinoma) and excluded involvement of glossogingival sulcus in 9 cases. Also these images helped to correctly localise small lesions of oral tongue in 12 cases that were inconspicuous on routine MR images due to apposed mucosal surfaces [Figure - 6].

   Discussion Top

Visual inspection & bimanual palpation are the corner stones of diagnosis of diseases of the oral cavity. Clinical examination however could underestimates deep spread of tumors and thereby the submucosal extent and limiting accurate pretreatment staging of disease. Imaging provides additional staging information like precise location and local extent of the tumor which help in the selection of most effective treatment option and extent of surgical excision. While lesions involving the buccogingival sulcus or gingiva are best treated by surgery or external beam radiotherapy, localised lesions of buccal mucosa are preferentially treated with interstitial implants [5]. MRI offers an excellent aid for evaluation of tumors of oral cavity due to direct visualization of soft tissue in multiple planes. Apposed mucosal surfaces limit MR evaluation of oral malignancies. Additional images taken in this study with dynamic maneuvers during MR examination have shown to overcome limitations of routine MRI and provided useful information of clinical significance about the origin and local extent of tumor.

Weissman et al [2] and Bredesen et al [3] showed usefulness of distended cheek CT scan to study the lesions of oral vestibule. We performed distended cheek MR imaging that provided additional information which includes better visualization of lesions, besides exact location of small inconspicuous lesions in the cheek and origin of bulky or exophytic lesions. Also these images better defined involvement of gingiva in cases of carcinoma cheek, involvement of cheek in case of carcinoma of gingiva & involvement of buccogingival sulci. In cases of a tumor of retromolar trigone these images helped in confirming or excluding involvement of cheek or gingiva.

With the tongue deviated away from the gingiva we found the glossogingival sulcus better exposed to confirm or exclude its involvement. Also small lesions in the lateral border or tip of the tongue were unequivocally defined that were otherwise inconspicuous on routine MR imaging.

These additional maneuvers are simple, can be easily taught and patients compliance is good. Such maneuvers added small additional time to the total scan duration. We find, these images with dedicated dynamic maneuvers increase the diagnostic confidence and may show tumoral involvement not apparent on routine MR images.

In conclusion, imaging with added maneuvers allows more detailed evaluation of origin and local extent of tumor in oral malignancies and should supplement the conventional MR imaging in selected cases.

   Acknowledgements Top

We acknowledge the contribution of Mr. Pradeep Negi (Technologist) & Mrs. Vandana Pal for helping in the preparation of the manuscript.

   References Top

1.M. Ozturk, I Yorulmaz, E Guney and N Ozean. Masses of the tongue and floor of the mouth: findings on magnetic resonance imaging. Eur. Radiol 2000; 10:1669 - 1674.  Back to cited text no. 1    
2.Jane L. Weissman and Richard L. carrau. "Distended cheek" CT improves evaluation of the oral cavity. Am J Neuroradiol 2001; 22:741-744.  Back to cited text no. 2    
3.K.Bredesen, T.M. Aalokken and A. Kolbenstvedt. CT of oral vestibule with distended cheeks. Acta Radiologic 2001, 42: 84-87.  Back to cited text no. 3    
4.Romrell LJ, Mancuso AA, Larkin LH, Rarey KE, Mahan PE, Ross MH (ed). Sectional anatomy of the head and neck with correlative diagnostic imaging. Philadelphia; Lea & Febiger, 1994; 146-160.  Back to cited text no. 4    
5.James T.Parson, William M. Menden hall, Rodney R. Millon. Radiotherapy of tumors of oral cavity. In Tawley, Panje, Batsakis, Lindberg (ed): comprehensive management of head and neck tumors. W.B. Saunders company, Philadelphia; 1999; 695-719.  Back to cited text no. 5    

Correspondence Address:
R Oberoi
GG-1-64/C, Vikaspuri, New Delhi-110085
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-3026.29024

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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]


[Table - 1]


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