Dentomaxillofacial Radiology (2015) 44, 20140229

ª 2015 The Authors. Published by the British Institute of Radiology

birpublications.org/dmfr

RESEARCH ARTICLE
Visibility of different foreign bodies in the maxillofacial region
using plain radiography, CT, MRI and ultrasonography: an
in vitro study
1
R Javadrashid, 1D F Fouladi, 1M Golamian, 1P Hajalioghli, 1M H Daghighi, 2Z Shahmorady and
1
M T Niknejad
1
Department of Radiology, Imam Reza Teaching Center, Tabriz University of Medical Sciences, Tabriz, Islamic Republic
of Iran; 2Department of Oral Radiology, Faculty of Dentistry, Birjand University of Medical Sciences, Birjand, Islamic
Republic of Iran

Objectives: To compare the usefulness of four imaging modalities in visualizing various

foreign bodies of different sizes.
Methods: Foreign bodies of four sizes (0.5, 1, 2 and 3 mm) including metal, tooth, wood,
plastic, stone, glass and graphite were embedded in six fresh sheep heads on bone surface
between the corpus mandible and muscle, and inside the tongue muscle. A human dry skull
served as an air-filled space. Plain radiography, CT, MRI and ultrasonography were used,
and four skilled radiologists rated the findings individually.
Results: All embedded foreign bodies except wood were best visualized using CT. Wood
could only be detected using ultrasonography, and then only when fragments were .0.5 mm
in size. Plain radiography and CT were almost equally accurate in visualizing metal and
graphite. MRI was the least useful imaging technique.
Conclusions: In cases with suspected foreign bodies in the maxillofacial region, CT seems to
be the optimal initial imaging study. Wood, however, could only be detected using
ultrasonography.
Dentomaxillofacial Radiology (2015) 44, 20140229. doi: 10.1259/dmfr.20140229

Cite this article as: Javadrashid R, Fouladi DF, Golamian M, Hajalioghli P, Daghighi MH,
Shahmorady Z, et al. Visibility of different foreign bodies in the maxillofacial region using plain
radiography, CT, MRI and ultrasonography: an in vitro study. Dentomaxillofac Radiol 2015;
44: 20140229.

Keywords: foreign body; imaging technique; maxillofacial region; visibility

Introduction

Foreign bodies offer a diagnostic challenge to the sufficient visualization and meticulous localization of
maxillofacial surgeon. About one-third of foreign bod- the embedded fragments.6–8
ies go unnoticed during initial examinations,1 rendering In general, selecting an imaging technique to opti-
it necessary to employ an imaging technique in sus- mally visualize a suspected foreign body relies upon the
pected cases.2 Using an inappropriate imaging modality, composition, size and location of the fragments.9,10
however, could result in untoward health-related Glass fragments, wood splinters, plastic particles and
consequences.3–5 In addition, creating an effective metallic objects are the most commonly encountered for-
weighted pro–con list of foreign body removal requires eign bodies in emergency departments.11 Comparatively,
tooth, stone and graphite are not so frequent, but they
Correspondence to: Dr Masoud Golamian. E-mail: [email protected] may cause diagnostic worries if left unrecognized.12–16
This study was supported by RJ. When a foreign object accidentally penetrates into the
Received 30 June 2014; revised 22 November 2014; accepted 25 November 2014 body, it may lodge in an air-filled space, soft tissues or
 Foreign bodies and imaging techniques
2 of 6 R Javadrashid et al

between bones and muscles.9 Conventional plain ra- rotation time, 0.37 s; resolution, 0.4 mm; increment,
diographs, CT, ultrasonography and MRI are used 0.5 mm; and slice thickness, 1 mm.
routinely at trauma settings for detecting and localizing
such foreign bodies.11 Image post processing was performed using a dedi-
Therefore, this study sought to compare capability of cated software package (Syngo® DynaCT Leonardo;
plain radiography, CT, MRI and ultrasonography in Siemens).
visualizing metal, tooth, wood, plastic, stone, glass and
graphite foreign bodies of different sizes inside soft tis- – MRI: MR images were acquired using Siemens
sue and between bone and muscle in a sheep head Avanto 18 Channel 1.5 T machine with a special
model, as well as in an air-filled space. head coil. The conventional setting for imaging the
human brain was used. The sequences used consisted
of T1 weighted fast-spin echo (echo time, 13 ms;
repetition time, 600 ms; number of excitations, 2;
Methods and materials field of view, 16 cm; matrix, 256 3 256 pixels) and
proton density/T2 weighted fast-spin echo (echo time,
Foreign bodies 89 ms; repetition time, 3500 ms; number of excita-
Metal (iron), tooth (both enamel and dentin), wood, tions, 2; field of view, 16 cm; matrix, 256 3 192
plastic (polyvinyl chloride), stone, glass and graphite pixels). Both sagittal and coronal planes were used
were used as foreign bodies (Figure 1) in this in vitro with a cross-section thickness of 3 mm and spacing
study. They were cut into similar shapes of 4 sizes (di- of 0 mm.
mensions: 0.5, 1, 2 and 3 mm). – Ultrasonography: ultrasound scanning was performed
using an ultrasound system (Toshiba Nemio 30,
Specimens 7.5 MHz linear probe for visualizing superficial tissues;
Six fresh sheep heads (1 day after death) and a dry Toshiba, Tokyo, Japan). This modality was not used
human skull were used. All imaging studies were for air-embedded fragments.
performed on the same day. Fragments were placed at
two locations in the sheep heads: (i) bone surface on
the corpus mandible through a slot in the exterior Analysis
covering muscle, and (ii) inside the muscle through an A previously described four-point scoring scale ranging
incision at the midline of the tongue. from 0 to 1414 was used for assessing the visibility of
A dry human skull was used as an air-filled space. foreign bodies (Table 1). Four skilled radiologists with
To assess false positivity, some empty slots were also over 8 years’ academic experience were solicited to re-
made. view and evaluate images independently. The average of
the results was recorded after the observations. The
Imaging studies observers were unaware of the composition, place or the
number of embedded foreign bodies.
– Conventional plain radiography: the conventional
setting for imaging the human skull was used. Both
anteroposterior and lateral images were taken. Results
Exposure settings were 75 kVp and 20 mA.
– CT: Somatom® Sensation 16 CT scan machine An excellent inter-rater agreement17 was present be-
(Siemens Healthcare, Forchheim, Germany) was tween the observers (average Cohen’s kappa 5 84%).
used. The conventional setting for imaging the Visibility scores are set out in Table 2.
human head was used; the reconstruction matrix size,
512 3 512 pixels; kVp, 110; helical pitch, 1; gantry Metal
All metal foreign bodies were best visualized on radio-
graphs (Figure 2) and CT images. Because of artefacts,
MRI was not accurate in detecting metal. Ultrasonography
Table 1 Four-point scoring scale for image interpretation14
Score Quality Definition
14 Excellent Excellent resolution of details and excellent
visibility, good demarcation from
surroundings
13 Good Good resolution of details, demarcation from
surroundings, clear visibility
12 Fair Insufficient resolution of details, insufficient
visibility, insufficient demarcation
11 Bad Details not resolved, bad demarcation from
Figure 1 Materials used as foreign bodies (from left to right: plastic, surroundings, bad visibility
tooth, graphite, wood, stone, glass and metal). 0 No image Invisible

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 Foreign bodies and imaging techniques
R Javadrashid et al 3 of 6

performed better than did MRI, but it was less accurate In conformity with previous reports,10,14,18,19 while all
than were radiography and CT. metallic foreign bodies were visualized perfectly in ra-
diographs and CT images, only large ones were de-
Tooth tectable by ultrasound; and MRI was the least useful
CT was the best imaging technique, followed by radi- modality. Because of strong magnetic fields, hazardous
ography, ultrasonography and MRI, respectively. movements may occur during MRI if metallic frag-
ments are present within soft tissues.20
Wood Although rarely encountered as a foreign body,21 an
Wood could be only detected by using ultrasonogra- undiscovered embedded tooth in the maxillofacial re-
phy and only when fragments were .0.5 mm in size gion may cause diagnostic problems.12 As reported
(Figure 3). previously,10 CT was the best imaging technique for
visualizing teeth, followed by radiography, ultrasound
Plastic and MRI. Despite using both enamel and dentine, ra-
CT was the best imaging technique (Figure 4), followed diography did not perform as well as expected for radio-
by ultrasonography and radiography/MRI. The small- opaque objects in detecting teeth, possibly owing to
est fragments (0.5 mm) were not detected by any close radio-opacities of the bone and teeth in a densely
modality. packed area such as the maxillofacial region.
Because of usually initial minor trauma22,23 and low
Stone visibility on plain radiographs,24 missed wood foreign
CT was the best imaging modality, followed by radi- bodies are common. Such undiagnosed foreign bodies
ography, MRI (Figure 5) and ultrasonography. may cause persistent infection because they are usually
dirty and carry many microorganisms.25,26
Glass On the basis of our findings, wood could be only
CT was the most accurate imaging method, followed by detected using ultrasonography and only when frag-
radiography, ultrasonography and MRI. ments were .0.5 mm in size.
In line with this, Ginsburg et al27 showed that su-
Graphite perficially retained wooden foreign bodies, when not
Plain radiography was the best imaging technique, fol- obscured by overlying gas or bone, can be most re-
lowed by CT, MRI and ultrasonography. liably visualized with ultrasonography through pro-
ducing a detectable echogenic structure with acoustic
shadowing. Other investigators have also suggested ul-
Discussion trasonography as the imaging method of choice for visu-
alizing wooden particles embedded in soft tissues.14,27–31
We compared the suitability of conventional plain ra- CT was the best imaging technique for visualizing
diography, CT, MRI and ultrasonography for visual- plastic foreign bodies, only when fragments were
izing different foreign bodies of various sizes placed in .0.5 mm in size in the present work, followed by ul-
three locations. trasonography and MRI/radiography. Possibly because

Table 2 Visibility scores of foreign bodies embedded on bone surface (BS), in muscle (M) and in air (A) using radiography, CT, MRI and
ultrasonography
Materials and locations
Metal Tooth Wood Plastic Stone Glass Graphite
Modality Size (mm) BS M A BS M A BS M A BS M A BS M A BS M A BS M A
Radiography 0.5 14 14 14 0 0 0 0 0 0 0 0 0 12 0 0 0 0 0 13 12 12
1.0 14 14 14 0 11 0 0 0 0 0 0 0 12 11 12 11 0 0 13 13 13
2.0 14 14 14 11 12 12 0 0 0 0 0 11 14 13 13 12 11 12 13 13 13
3.0 14 14 14 12 13 13 0 0 0 11 11 12 14 13 13 12 12 13 14 14 14
CT 0.5 14 14 14 11 11 12 0 0 0 0 0 0 13 13 13 13 12 14 11 12 11
1.0 14 14 14 13 14 14 0 0 0 11 12 12 14 14 13 13 14 14 13 13 13
2.0 14 14 14 14 14 14 0 0 0 13 13 14 14 14 14 14 14 14 14 14 14
3.0 14 14 14 14 14 14 0 0 0 14 14 14 14 14 14 14 14 14 14 14 14
MRI 0.5 11 11 NU 0 0 0 0 0 0 0 0 0 13 13 0 0 0 0 13 13 0
1.0 11 11 NU 0 12 0 0 0 0 0 0 0 13 13 0 0 0 0 13 13 0
2.0 11 11 NU 11 12 0 0 0 0 12 0 0 13 13 0 11 12 0 13 13 0
3.0 0 0 NU 11 13 0 0 0 0 12 12 0 14 13 0 12 12 0 14 13 0
Ultrasound 0.5 0 0 NU 0 0 NU 0 0 NU 0 0 NU 0 0 NU 0 0 NU 0 0 NU
1.0 0 0 NU 0 0 NU 11 11 NU 0 0 NU 0 0 NU 0 0 NU 0 0 NU
2.0 13 13 NU 13 13 NU 14 14 NU 13 13 NU 13 13 NU 13 13 NU 13 13 NU
3.0 13 14 NU 13 13 NU 14 14 NU 13 13 NU 13 14 NU 13 13 NU 13 13 NU
NU, not used.

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Figure 4 Visibility of plastic (size, 2 mm) in the air using CT. Arrow
indicates foreign body.

bodies, for example, 1 mm in size, the latter proved

useless.
Hyperechoic areas with posterior shadows and re-
verberation artefacts are essential for detecting for-
eign bodies by ultrasound.33 When foreign bodies are
small, however, these clues may disappear or become
overlooked.19
Visibilities of stone and metallic foreign bodies were
similar in this study; a finding in line with the results
of a previous study.14
Figure 2 Visibility of metal (size, 3 mm) on the bone surface using In conformity with previous reports,14,27,32 CT was
radiography. Arrow indicates foreign body.
the most accurate method for detecting glass, followed
by radiography, MRI and ultrasound, respectively.
Penetrating pencil-tip injuries are frequent among
of using different types and sizes of plastic fragments,
children, and the embedded graphite core may increase
reports are discordant in this regard.14,27,28,32 For ex-
morbidity or may lead to misdiagnosis.15,16 As reported
ample, while CT and ultrasound were similarly accurate
in another study,34 CT was the best imaging modality to
in detecting large plastic fragments, for smaller foreign
detect graphite in the present work.

Figure 3 Visibility of wood (size, 2 mm) inside the muscle using Figure 5 Visibility of stone (size, 1 mm) inside the muscle using MRI.
ultrasonography. Arrow indicates foreign body. Arrow indicates foreign body.

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R Javadrashid et al 5 of 6

In cases with suspected foreign bodies, conventional In vitro models lack the ability to reproduce in-
plain radiography is usually the initial imaging tech- flammatory reactions around foreign bodies. So, con-
nique.20 It is widely available, simple and sufficiently trast media cannot be used; the influence of body
accurate in detecting radio-opaque objects, but it may reaction on image quality in chronic cases cannot be
fall short, as shown in the present work, of the goal of appreciated;40 and the tissue swelling around an em-
identifying radiolucent objects or defining their precise bedded foreign body as an indirect clue for its presence
localization.35 is missing.1
CT is more accurate,9 particularly when a non- Because of limited room inside the maxillofacial
opaque object is anticipated11 or the foreign body is lo- sinuses, a dry human skull served as an air-filled space
cated inside pneumatized areas.14 in the present work. The use of a dry human skull
MRI is sophisticated, expensive and not widely avail- without wet soft tissues, however, may seem irrelevant
able. This modality cannot be used initially in cases with to the clinical application; a limitation that should be
suspected foreign body with unknown composition. In acknowledged.
addition, artefacts could compromise clear visualization of Finally, several parameters such as Hounsfield units,
metal, glass, graphite and even plastic.10,36 acoustic properties, water content and relaxation time
Ultrasonography causes no radiation exposure, is may be helpful for better interpretation of results in
inexpensive, provides real-time imaging and is available future studies.
widely even at bedside.37,38
In the case of superficial, non-opaque foreign bod-
ies,11 ultrasonography is highly sensitive.38 To detect Conclusion
deeply embedded foreign bodies high frequency ultra-
sonography may be more accurate than the conven- CT was the method of choice in visualizing metal,
tional low-frequency (3.5–5.0 MHz) technique.39 It tooth, plastic, stone, glass and graphite foreign bodies in
should be noted that, however, low-frequency trans- the maxillofacial region. Plain radiography could be
ducers are more available than high-frequency trans- considered as the method of second choice in visualizing
ducers in emergency departments.28 metal, tooth, stone, glass and graphite. Wood could
Owing to a reason that needs no further explanation, only be detected using ultrasonography, and then only
this study was not an in vivo examination. when fragments were .0.5 mm in size.

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