DENTOALVEOLAR SURGERY

Diagnosis of Dental Abnormalities in

Children Using 3-Dimensional Magnetic
Resonance Imaging
Olga Tymofiyeva, PhD,* Peter C. Proff, MD, DMD,y Kurt Rottner, DMD, PhD,z
Markus D€ uring, DiplPhys,x Peter M. Jakob, PhD,k
urgen Richter, DMD, DiplIng, PhD{
and Ernst-J€
Purpose: To assess the feasibility of magnetic resonance imaging (MRI) of dental abnormalities in
children.
Materials and Methods: The study included 16 patients (mean age, 10.8 yr) prospectively selected
from 1,500 orthodontic patients. The selected patients included 3 with a mesiodens, 9 with supernumer-
ary teeth other than a mesiodens, 1 with gemination, 1 with dilacerations, 1 with transmigration, and
1 with transposition. Three-dimensional (3D) images were acquired on a 1.5-T MRI scanner using a 3D
turbo spin echo pulse sequence with a voxel size of 0.8  0.8  1 mm. The measurement time was 4
to 5 minutes.
Results: Using natural MRI contrast, the teeth, dental pulp, mandibular canal, and cortical bone could be
clearly delineated. The position and shape of malformed teeth could be assessed in all 3 spatial dimensions.
Conclusion: MRI was found to be a well-tolerated imaging modality for the diagnosis of dental abnormal-
ities in children and for orthodontic treatment and surgical planning. Compared with conventional radi-
ography, dental MRI provides the advantage of 3-dimensionality and complete elimination of ionizing
radiation, which is particularly relevant for repeated examinations in children.
Ó 2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1-11, 2013

Different genetic and environmental factors can cause
abnormalities in tooth development, manifesting as
changes in the size, shape, position, and number of
teeth. There are 2 major groups of dental abnormali-
ties: morphologic and developmental. Morphologic
dental abnormalities include abnormalities of the num-
ber (eg, supernumerary teeth including a mesiodens),
form and size (eg, gemination), and position of teeth
(eg, transmigration and transposition). An example of
developmental dental abnormalities is dilaceration,
which is found in 1.8% to 15% of teeth.1-3 The
prevalence rates in the literature for supernumerary
teeth range from 0.3% to 3.8%,3-6 with a mesiodens
(0.15% to 1.9%) being the most frequent extra tooth.7
Form and size anomalies, such as fusion and gemina-
tion, are rare conditions, with prevalences of 0.1%
to 1%.3,8 Variations of tooth position are similarly
infrequent, with a prevalence lower than 0.5%.9-11
Radiographs are routinely used for the diagnosis
of dental abnormalities and for orthodontic treat-
ment and surgical planning. However, radiographic
images provide only limited information, especially

Received from the University of W€

urzburg, W€
urzburg, Germany.
*Research Assistant, Department of Experimental Physics 5.
yProfessor, Department of Orthodontics, Dental School,
University of Regensburg, Regensburg, Germany.
zGuest Research Fellow, Department of Prosthodontics, Dental
School.
xResearch Assistant, Department of Experimental Physics 5.
kProfessor, Department of Experimental Physics 5; Magnetic
Resonance Bavaria eV, W€
urzburg, Germany.
{Professor, Department of Prosthodontics, Dental School.
Parts of this article have been published (Tymofiyeva O: Magnetic
Resonance Imaging in Dental Medicine. Dissertation, University of
W€
urzburg. G€
ottingen, Sierke-Verlag, 2010).
Address correspondence and reprint requests to Dr Tymofiyeva:
Department of Radiology and Biomedical Imaging, University of
California–San Francisco, 1700 4th St, Byers Hall Suite 102, UCSF
Box 2512, San Francisco, CA 94158; e-mail: Olga.Tymofiyeva@ucsf
.edu
Ó 2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/00205-X$36.00/0
http://dx.doi.org/10.1016/j.joms.2013.02.014

1
2 DIAGNOSIS OF PEDIATRIC DENTAL ABNORMALITIES

(3D) imaging becomes necessary in most cases. Appli-

FIGURE 1. Simplified scheme of dental structures and their MRI
properties. Visible on MRI: 1, dental pulp; 2, bone marrow; 3, man-
dibular canal; 4, gingiva (and tongue, palate, facial soft tissues,
etc); 5, saliva. Invisible on MRI: 6, enamel; 7, dentin; 8, cortical
bone.
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities.
J Oral Maxillofac Surg 2013.
for overlapping dental structures. When multiple views
are acquired, mental reconstruction still can be chal-
lenging and lead to wrong results. Three-dimensional
cation of dental computed tomography (CT) has limita-
tions owing to a high radiation dose. This limitation is
especially important because most patients with dental
abnormalities are children, and repetitive examinations
are often required. Relatively new variations of dental
CT, namely cone-beam CT and digital volume tomogra-
phy, allow for a significant decrease of the radiation
dose12 and have been considered for 3D visualization
of dental abnormalities, such as supernumerary
teeth.13-15
Another imaging modality, magnetic resonance
imaging (MRI), is quite new in dental radiology. The
technique does not use ionizing radiation, is safe
when no contraindications are present (cardiac pace-
makers, implanted cardiac defibrillators, aneurysm
clips, neurostimulators, metallic foreign bodies in the
eyes, etc), and has no limitations in the frequency of
examinations. MRI is based on the nuclear magnetic
resonance phenomenon, which takes place when nu-
clei of certain atoms (usually hydrogen in medicine)
are placed in a strong static magnetic field and absorb

FIGURE 2. Panoramic radiograph showing an abnormal structure in the apical region of the lower right first and second premolars.
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.
TYMOFIYEVA ET AL 3

FIGURE 3. Three cross-sectional views from a 3-dimensional magnetic resonance imaging dataset (top and lower LEFT) and a panoramic
curved cut view (lower RIGHT) showing supernumerary teeth in the apical region of the lower right first and second premolars. The largest struc-
ture has the shape of a tooth with detectable pulp (arrows).
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.

energy of an alternating magnetic field of a specific,
resonant frequency. The use of spatially varying mag-
netic fields makes it possible to spatially encode the
nuclei and perform tomographic imaging. The signal
measured on MRI usually originates from soft tissues
and liquids in the human body. Common objects of
interest in dentistry, such as the teeth and jawbone,
usually appear black on MR images. This is caused by
low water content and very short relaxation constants
(T2) of the hydrogen atoms present in these tissues.
The scheme presented in Figure 1 shows the MRI
properties of dental structures that affect their appear-
ance on MR images. The dental pulp, jawbone marrow,
mandibular canal containing the mandibular artery
and vein and the alveolar nerve, saliva, gingiva, facial
soft tissues, tongue, and palate produce a signal on
clinical MRI. Conversely, there is no measurable signal
from dental enamel, dentin, cortical bone, and air.
However, even without the use of special solid-state
MRI techniques, the latter structures can be measured
4 DIAGNOSIS OF PEDIATRIC DENTAL ABNORMALITIES
FIGURE 4. 3D rendering of segmented MRI dataset showing abnormal structures (red) and the mandibular canal (pink).
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.
indirectly from the contrast with the adjacent signal-
emitting structures. Thus, MRI has been shown to en-
able 3D measurement of the mandible because of the
contrast between the cortical bone and the surround-
ing signal-emitting soft tissue.16 The crowns of teeth
prepared for dental restorations can be digitized with
a very high resolution using oral contrast medium.17,18
Impacted teeth can be visualized and their positions in
all 3 spatial dimensions can be assessed based on the
contrast between the teeth and the surrounding
tissue, such as the gingiva, tongue, cheek, saliva, and
jaw bone marrow.19 The purpose of this prospective
study was to assess the feasibility of using MRI for den-
tal abnormalities in children.
Materials and Methods
The study protocol was approved by the research
ethics committee of the Dental School of the Univer-
sity of Regensburg and written informed parental con-
sent was obtained. The study included 16 patients
(mean age, 10.8 yr; range, 8 to 15 yr) prospectively se-
lected from 1,500 orthodontic patients. The selection
criteria were the presence of abnormalities of the size,
shape, position, and number of teeth. Thus, the se-
lected patients included 3 with a mesiodens, 9 with su-
pernumerary teeth other than a mesiodens, 1 with
gemination, 1 with dilaceration, 1 with transmigration,
and 1 with transposition. The male-to-female ratio
was 2.2:1.
Three-dimensional images were acquired using
a 1.5-T MRI scanner (Magnetom Avanto, Siemens Med-
ical Solutions, Erlangen, Germany) in combination
with a 4-channel multifunctional radiofrequency coil
array (Noras MRI Products, H€ ochberg, Germany).20
During the scan, a patient lied supine on the patient ta-
ble with the coil fixed so that its surface was slightly
pressed against the patient’s lips to provide better
signal reception. The children were asked to keep
their mouths closed naturally and not move during
the scan. A 3D turbo spin echo pulse sequence was
applied, with a turbo factor of 17. The period of the ra-
diofrequency excitations (time to repeat) was 1 second
and the echo time was 100 ms. On average, the
covered field of view was 10  6  5 cm and the
matrix was 128  76  44, resulting in a voxel size
of about 0.8  0.8  1 mm. The measurement time
was 4 to 5 minutes, which was acceptable for children.
Taking into account the additional time it took to famil-
iarize each child with the MRI scanner, provide ear
plugs, position the child on the patient table, and per-
form the ‘‘localizer’’ scans, the entire procedure took
about 15 minutes per child.
Three different visualization techniques were
used for the evaluation of the results. The standard
cross-sectional views from the 3D datasets and a pan-
oramic curved cut view were immediately obtained
on the MRI workstation. To provide better visualiza-
tion for treatment and surgical planning,19 the data
were segmented and rendered using 3D visualization
software Amira (ZIB, Berlin, Germany). The software
allowed for semiautomatic segmentation of the den-
tal structures using a region-growing algorithm and
3D rendering of the surface of the structures
of interest.
Results
The measurement procedure and duration of 4 to
5 minutes were well tolerated by all children. No
TYMOFIYEVA ET AL 5

sedation was used in the study. MRI yielded a clear sep-
aration between the tooth substance and the sur-
rounding tissues. The position and shape of
malformed teeth could be assessed in all 3 spatial di-
mensions. The visualization software allowed viewing
of the rendered structures from arbitrary angles.
Figures 2 through 4 show an example of
supernumerary teeth in a 13-year-old male patient.
An abnormal structure in the apical region of the lower
right first and second premolars was visible on a pano-
ramic radiograph (Fig 2). Cross-sectional views from
a 3D MRI dataset (Fig 3) and 3D rendering (Fig 4)
allowed for better analysis of the structure. Multiple
teeth, with the pulp visible in the largest of them,
could be distinguished.
Examples of panoramic radiographs and correspond-
ing 3D MRI of dental abnormalities are shown in
Figures 5 through 10. Owing to the contrast between
the teeth and the surrounding tissue, the surface of
the teeth of interest could be reconstructed using
semiautomatic segmentation. The dental pulp had
a high MR signal and, therefore, could be visualized
in the tooth substance, thus providing valuable
diagnostic information in many cases.
Discussion
The present results show that MRI is well suited to
the diagnosis of dental abnormalities in children and
for orthodontic treatment and surgical planning.

FIGURE 5. Panoramic radiograph (top) and 3D rendering of MRI data (bottom) showing a mesiodens.
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.
6 DIAGNOSIS OF PEDIATRIC DENTAL ABNORMALITIES

FIGURE 6. Panoramic radiograph (top) and 3D rendering of MRI data (bottom) showing dilaceration.
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.

Dental abnormalities were visualized from the contrast
to the adjacent signal-producing dental structures. The
dental pulp, bone marrow, gingiva, saliva, facial soft
tissues, tongue, and palate provided a signal on clinical
MRI. Signal intensity from different tissues was influ-
enced by the complex combination of inherent tissue
properties and measurement parameters of the pulse
sequence used. In addition, MR contrast medium
can be applied to increase the signal from a tissue.
For example, intravenous contrast medium can be
applied to increase the MRI signal from the inferior
alveolar nerve21-23 or dental pulp.24-27 Oral contrast
medium can be applied to increase the signal from
the oral cavity for indirect visualization of the tooth
surface17,18 or carious lesions.28
In recent years, 3D imaging techniques have con-
tinued to evolve in dentistry beyond maxillofacial sur-
gical planning. Dental MRI is the next such
technique, adding a third dimension to treatment
planning, to be introduced after techniques based
on CT and digital volume tomography. Three-
dimensional imaging provides obvious advantages
to oral diagnostics such as of dental abnormalities.
The advantages of capturing and viewing spatial rela-
tions are well known and have been widely appreci-
ated in the literature. Mental reconstruction gives
way to technology to avoid sensory overload. More-
over, 3D reconstruction images do not yield magnifi-
cation distortions such as those inherent on planar
imaging. The 3D rendering can be rotated and viewed
TYMOFIYEVA ET AL 7

FIGURE 7. Panoramic radiograph (top) and 3D rendering of MRI data (bottom) showing gemination.
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.

by the surgeon from arbitrary angles. For supernu-
meraries or other abnormalities, the proximity to crit-
ical anatomic landmarks, such as adjacent teeth or the
mandibular canal, and optimal surgical access can be
determined in 3 dimensions. The significance of accu-
rate surgical and orthodontic treatment planning in
dental abnormalities as it pertains to critical struc-
tures cannot be overstated. The additional informa-
tion provided by 3D MRI may help the surgeon to
resolve the ambiguity of 2D radiographs and thus in-
crease patient safety and make treatment more
predictable.
In addition to the potentials discussed thus far,
there are limitations to dental MRI, as with all other
imaging techniques. The general restrictions to the
indication of diagnostic MRI also apply. Among the is-
sues that require further evaluation, probably the
most obvious is susceptibility artifacts. Thus far, arti-
facts caused by ferromagnetic materials used for im-
plants, brackets, and crowns have been the focus of
interest. These materials may alter the precession fre-
quencies of protons in the adjacent tissues and distort
the linear magnetic field gradients, resulting in signal
loss from spin dephasing and mismapping artifacts as-
sociated with frequency shifts.29,30 Empirical
evidence is conflicting for gold alloys31-33 and
titanium alloys,34-37 which may contain traces of
ferromagnetic substances and compromise the
image quality of dental MRI. In contrast, large
ferromagnetic effects are generally supposed to be
8 DIAGNOSIS OF PEDIATRIC DENTAL ABNORMALITIES

FIGURE 8. Panoramic radiograph (top) and 3D rendering of MRI data (bottom) showing transmigration.
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.

induced by stainless-steel appliances such as ortho-
dontic brackets.37-41 A recent study on the potential
influence of dental materials specifically on dental
MRI has classified common materials as fully
compatible, compatible I, and noncompatible.42
Only the presence of materials from the third, or non-
compatible, group, such as stainless steel or cobalt-
chromium alloy appliances, has been described as
a serious difficulty for any dental MRI application.42
Because the magnitude of susceptibility artifacts is
related to the type of imaging sequence used, spin
echo sequences with a short echo time have been
suggested to decrease the severity of the susceptibil-
ity artifact and therefore were used in the pres-
ent study.42
The entire MRI procedure in the present study was
very short, only 15 minutes in total, uncomplicated
and could be easily translated into a clinical setting.
No sedation was used. While the youngest patients
in this study were 8 years old, younger children might
require sedation. However, recent efforts in some hos-
pitals to decrease sedation for MRI procedures have
shown promising results.43 A sedation-decreasing pro-
gram can consist of multiple components, including
hiring a certified child-life specialist, installing MRI
video goggles, and instituting a culture change that
emphasizes the need to avoid sedating children for
MRI whenever possible.43
The amount and accuracy of information provided
by dental MRI and its benefits in increased treatment
TYMOFIYEVA ET AL 9

FIGURE 9. Panoramic radiograph (top) and 3D rendering of MRI data (bottom) showing transposition.
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.

safety, success, and predictability need to be weighed
against its cost, convenience (eg, measurement
time), and the expertise required. Studies have
shown that the accuracy of MRI is comparable to
that of dental CT.44,45 In a more recent study, MRI
showed a comparable accuracy and better visibility
in the detection of teeth and periodontal anatomy
compared with cone-beam CT.46 When weighed
against other 3D imaging techniques, however, the
most striking advantage of dental MRI is the complete
absence of ionizing radiation. This is especially im-
portant in view of a recent study showing that indi-
viduals who reported having dental panoramic
radiographs taken at younger than 10 years had
a 4.9 times increased risk of meningioma.47 A deeper
discussion of the economic aspects and technical
properties of MRI compared with cone-beam CT
can be found in a recent publication on MRI of im-
pacted teeth.19
Dental MRI is a safe, well-tolerated imaging
method that can be used for the diagnosis of dental
abnormalities in children and for orthodontic treat-
ment and surgical planning. Compared with con-
ventional radiographs, MRI provides the advantage
of 3D morphology. This advantage can help opti-
mize surgical treatment and increase patient safety.
Moreover, MRI is accompanied by the complete
elimination of ionizing radiation, which is par-
ticularly relevant for repeated examinations in
children.
10
FIGURE 10. Panoramic radiograph (top) and 3D rendering of MRI data (bottom) showing supernumerary teeth (inverted).
Tymofiyeva et al. Diagnosis of Pediatric Dental Abnormalities. J Oral Maxillofac Surg 2013.
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