Frequency Ultrasound in Oral and Maxillofacial Imaging

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© Springer Nature Switzerland AG 2021

K. Orhan (ed.)Ultrasonography in Dentomaxillofacial

13. Ultra-High Frequency Ultrasound in Oral and Maxillofacial Imaging

Rossana Izzetti1  

Unit of Dentistry and Oral Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
Rossana Izzetti

UltrasonographyUltra-high frequency ultrasoundAnatomyMouth diseasesOral medicine

13.1 Introduction

Ultra-high frequency ultrasound (UHFUS) is a recently introduced ultrasonographic technique characterized by the use of ultrasound frequencies between 30 and 100 MHz, yielding improved spatial resolution at the expense of a shallower depth of penetration.

High-frequency techniques include UHFUS, High-frequency ultrasound (HFUS), and ultrasound biomicroscopy (UBM), which were originally introduced in the mid-90s in the preclinical setting for the study of animal models. In particular, preclinical applications have expanded in the last years and currently include the evaluation of developmental changes during embryogenesis, cardiac and brain development, tumor growth patterns and spread of metastases, and pharmacokinetics and pharmacodynamics of antineoplastic therapies in experimental murine models [1, 2].

For what concerns clinical setting, ultra-high frequencies find application in several medical fields, including vascular, musculoskeletal, small parts, and dermatological evaluation [36].

In particular, vascular applications include the study of radial artery, venous valves, peripheral vascularization, blood flow characteristics, arterial intima/media thickness, stiffness, and risk assessment of atherosclerosis. Musculoskeletal evaluation includes hand anatomy and planning of hand surgery, superficial joints, tendons and pulleys, medial menisci, carpal and tarsal tunnel, while small parts evaluation is mostly focused on nerves and lymph nodes. In dermatology, ultra-high frequencies are employed for the study and differentiation of cutaneous lesions (including melanoma), skin layers, hair follicles, and identification of foreign bodies [7].

Oral medicine is a recently introduced field of application, due to the possibility of ultra-high frequencies to provide high-resolution images of superficial structures [810].

13.2 Principles of UHFUS Imaging

Image generation in ultrasonography is characterized by the production of ultrasound waves and registration of reflected echoes after attenuation related to the passage of the waves inside different tissues. The return echoes are then converted into electric signals, and the signals into images.

Ultrasound wave frequency and depth of penetration are inversely proportional: the higher the frequency, the shallower the depth of penetration. In this sense, the use of ultra-high frequencies allows to image the superficial layers from the point of application of the probe, but on the other hand it allows to obtain micron-sized resolution.

Vevo MD (VisualSonics) is the first UHFUS equipment available for clinical use (Fig. 13.1). For the study of the oral cavity, 48 MHz and 70 MHz frequencies appear suitable to obtain high-resolution imaging of the superficial layers of the oral mucosa. In Table 13.1, the characteristics of 48 MHz and 70 MHz UHFUS probes are summarized.

Fig. 13.1

Vevo MD equipment is the first UHFUS system for medical use. (a) UHFUS appliance; (b) UHFUS probes; on the left, probe reaching frequency of 70 MHz, on the right 48 MHz probe

Table 13.1

Summary of technical characteristics of 48 MHz and 70 MHz UHFUS probes

Probe frequency

70 MHz

48 MHz

Center transmit

50 MHz

30 MHz


29–71 MHz

20–46 MHz

Axial resolution

30 μm

50 μm

Lateral resolution

65 μm

110 μm

Maximum depth

10.0 mm

23.5 mm

Image width (max)

9.7 mm

15.4 mm

Image depth (max)

10.0 mm

23.5 mm

Focal depth

5.0 mm

9.0 mm

Considering ultrasound physics, axial resolution is determined by the bandwidth of the pulse, while lateral resolution is the result of the ratio between focal distance and spatial dimension of the transducer multiplied for the wavelength. In this sense, 70 MHz frequencies provide 30 μm axial resolution and 65 μm lateral resolution, at the expense of an increase in attenuation in tissues, with a depth of penetration limited to 10.0 mm.

Ultra-high frequencies appear suitable when small anatomy is investigated. In general, if a region or a lesion to be scanned is <2 cm, 70 MHz can provide adequate detail and imaging of the lesion as a whole. If the area to be scanned is >2 cm, reduction in scanning frequencies is required, with 48 MHz probe allowing to image all the lesion with one scan. However, it is often advisable to perform a double scan regardless of lesions’ dimensions, as the two frequencies in most cases are complementary in diagnosis performance.

13.3 Components of Image Production

13.3.1 Performance of Intraoral UHFUS Scan

Intraoral UHFUS scan is generally performed with the patient in supine position, providing head stabilization with a headrest. In some cases, UHFUS performance can be chair-side to the dental chair thus improving patient positioning.

Head positioning varies depending on the area to be investigated. In particular, the following positions may be adopted for the following sites:

  • Buccal mucosa: the patient’s mouth is wide open, and the head is tilted right to image right buccal mucosa and left to image left buccal mucosa. In some cases, in particular, when exophytic lesions are to be investigated, the cheek may be gently stretched and slightly turned outward to contrast probe pressure during the scan. If the fornix is to be scanned, additional divarication may be needed.

  • Tongue: the patient’s mouth is open, and the tongue is gently pulled outwards with the support of a gauze to avoid sliding during examination. If the tongue dorsum is the object of the investigation, tongue is kept straight, while if the lesion involves tongue margins, the tongue has to be pulled contralaterally to expose the area of investigation. If the ventral aspect of the tongue is to be scanned, the patient can be asked to put the tip of the tongue against the palate in correspondence with the retroincisal papilla and to keep this position.

  • Lips: lip mucosa can be examined by gently pulling outwards the lip. No additional traction is generally required to perform the scan. In this case, the patient’s mouth can be kept closed, in order to decrease muscular tension on lip muscles.

  • Palate: palate imaging requires wide mouth opening, and head tilted right for the examination of right side of the palate and left for the scan of left palate. The probe is inserted from the contralateral side, to avoid interference with dental arches.

  • Mouth floor: mouth floor can be scanned by inserting the probe almost vertically or from the contralateral side. Patient’s mouth is wide open, and no additional traction is required. In some cases, in particular, for lesions located deeply in the mouth floor, it may be advisable to apply a gentle pressure extraorally from the submandibular area, in order to raise the mouth floor and to contrast probe pressure.

  • Gingiva: to image gingiva gentle divarication of lip or buccal mucosa is required. In general, no additional divarication is necessary.

A coupling medium (gel, saline solution) should be used to facilitate transmission of the ultrasound energy, and create a better interface for the imaging of the mucosal surface. Prior to examination beginning, a thin layer of US gel is applied inside a disposable sheath. Then the sheath is positioned on the UHFUS probe and cable and secured with supplied bands for the management of cross-infections. After protecting the probe, it is important to check for the presence of air bubbles which could affect ultrasound images, and eliminate them from the space between the transducer and the sheath. In some cases, extra application of coupling medium may be necessary to avoid compression of the shallower tissue layers, which could impair image quality.

13.3.2 Setting Image Acquisition Parameters

During the UHFUS examination, several parameters may be adjusted to improve image quality. Image depth depends on the transducer applied, and it corresponds to the total acquired depth of the non-zoomed image.

Gain control may be varied to adjust the visual intensity of the returning signal. In particular, an increase in gain brightens the image, while a decrease leads to darkening. In B-mode images, variations in Time Gain Compensation (TGC) adjust the ultrasound signal to compensate for minor attenuation for the signal returning from deeper situated tissues.

13.3.3 Strengths and Limitations Size and Cost

The main drawback of the use of UHFUS systems is the lack of dedicated probes for intraoral access, which can hinder full mouth examination in patients with limited mouth opening. Acquiring a UHFUS system is relatively costly compared to conventional US systems, although the benefits in terms of image quality and the opportunities for oral mucosa exploration are much higher compared to conventional US equipment. Fast Acquisition

UHFUS acquisition is fast, due to relatively easy accessibility to the oral cavity. The possibility to perform real-time measurements and evaluation of blood flow make the technique suitable for preoperative investigations. Moreover, the repeatability of UHFUS scan makes this technique a valuable tool for performing follow-up after surgical procedures involving the oral mucosa. Submillimeter Resolution

It is known that the higher the ultrasound frequencies, the lower the depth of penetration of the ultrasound wave. However, imaging of the shallower layers of the oral mucosa is also accompanied by higher spatial resolution, which in cases of 70 MHz frequencies can reach up to 30 μm. When dealing with small anatomy as one of the oral cavity, it is of utmost importance to obtain high-resolution images, which could support diagnosis performance. Moreover, oral lesions are in most cases confined to a maximum of 2 cm beneath the surface thus making UHFUS systems ideal for the study of the majority of oral diseases. Diagnostic imaging is going towards an increasing interest in micron-sized anatomy, and in this sense UHFUS reflects the need for submillimeter imaging of small anatomical parts. The detailed evaluation of oral mucosa therefore represents one of the most promising innovations in this field.

13.4 Normal Anatomy

13.4.1 Buccal Mucosa

UHFUS structure of buccal mucosa is characterized by a thin homogeneously hypoechoic layer corresponding to the mucosa. The submucosa appears as a well-defined, hyperechoic stratum below the mucosa. In the submucosal layer, it is possible to observe vascular structures appearing as roundish hypoechoic structures. In this region, the most important anatomical structure is represented by the facial artery, which on longitudinal scan appears as a linear structure with hypoechoic margins, and is characterized by pulsation and intense blood flow. Doppler mode shows mild vascularity, while intense blood flow is detected in correspondence with the facial artery. (Figs. 13.2 and 13.3).

Fig. 13.2

Normal anatomy of the buccal mucosa. (a) UHFUS aspect of the buccal mucosa; (b) Schematic exemplification of anatomy

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Aug 7, 2022 | Posted by in Oral and Maxillofacial Radiology | Comments Off on Frequency Ultrasound in Oral and Maxillofacial Imaging
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