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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 849-854

Simulating submandibular area with everyday-use materials in dental education: A didactic US study


1 Department of Oral and Maxillofacial Radiology, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
2 Department of Prosthetic Dentistry, Zonguldak Bulent Ecevit University, Zonguldak, Turkey

Date of Submission21-Sep-2021
Date of Acceptance07-Jan-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. G Geduk
Department of Oral and Maxillofacial Radiology, University of Zonguldak Bulent Ecevit, Faculty of Dentistry, Kozlu - 67100, Zonguldak
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1831_21

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   Abstract 


Background and Aim: The aim of our study is to prepare a head–neck phantom model for ultrasound suitable for submandibular anatomy to be used in the education of research assistants in the department of radiology in dentistry, and to compare different materials for this purpose. Materials and Methods: To make the planned phantom model, we used aluminum foil suitable for the curvature of the mandible instead of bone, pasta, or parsley stalk and balloon/glove to mimic the myofascial structure instead of muscles, tube of an infusion system instead of blood vessels, ketchup/mayonnaise/honey instead of gland structures (in a small balloon), and small balloons filled with water or mayonnaise with a tube of an infusion system or pipette instead of lymph nodes. Results: After the examinations, it was decided to put ballistic gel for soft tissue, aluminum foil for bone, spaghetti and ketchup in a balloon for muscle, mayonnaise in small balloons for lymph nodes, ketchup in a balloon for submandibular gland, and a tube of an infusion system for the artery. Conclusion: The submandibular region phantom can be a useful tool for learning the sonoanatomy of the head, neck, and submandibular region and improving the ability to use ultrasound. The advantage of the prepared model is that it is easy to use, prepare and apply materials accessible to any dentist, and can be used over and over again.

Keywords: Phantom, submandibular, ultrasound


How to cite this article:
Geduk G, Geduk S E, Seker C. Simulating submandibular area with everyday-use materials in dental education: A didactic US study. Niger J Clin Pract 2022;25:849-54

How to cite this URL:
Geduk G, Geduk S E, Seker C. Simulating submandibular area with everyday-use materials in dental education: A didactic US study. Niger J Clin Pract [serial online] 2022 [cited 2022 Jul 6];25:849-54. Available from: https://www.njcponline.com/text.asp?2022/25/6/849/347612




   Introduction Top


The ultrasound (US) device is a diagnostic tool based on the principle of sound waves moving at different speeds in different intensity tissues, reflecting and visualizing these waves.

Ultrasonography is used to view internal body structures such as tendons, muscles, joints, vessels, and internal organs. Ultrasonic images, also known as sonograms, are produced by sending ultrasound pulses to the tissue using a transducer-carrying probe containing material that produces a piezoelectric effect. According to ultrasound logic, the lower the frequency, the higher the penetration into tissues, but lower the potential image resolution.[1]

US can be used in many areas in dentistry. Classical uses such as salivary gland diseases, cervical lymphadenopathy, various soft tissue masses, chewing, and neck muscles are known. In addition to this, it has been reported to be used in many areas such as maxillofacial fractures, periapical lesions, examination of oral mucosa and various soft tissue lesions, evaluation of periodontal tissues, and implant dentistry, especially by intraoral approach.[2]

We can see that the use of US in dentistry in Turkey is very limited. It is known that the number of faculties using US devices from approximately 98 actively working dentistry faculties does not exceed 15. From this point of view, material support, software support, and usage variety for a less used tool do not increase and cannot be provided. With the use of US in dentistry within the scope of specialist training, the need for US training in faculties has started. Accessible US devices, trained instructors (experts), and materials to be used for practice are primarily required in this training.

When the learning models used in most of the new devices are examined, simulation studies can be seen in them. Considering the educational phantom models used in simulation practice, it is seen that there are very limited options for dentistry. Even when we look at the companies Bluephantom and CIRSINC, which are the most common brands in phantom models, we see that the anatomical structures that need to be looked at in the head and neck area are not included in the models and the prices of the models that are closest to the region examined by dentists are very high.[3],[4] Submandibular region and intraoral imaging cannot be performed in any of these models. Due to these difficulties, it is thought that there may be insufficiency in the ultrasound training included in the specialty curriculum and loss of quality in terms of patient service.

Due to the high prices, publications that make homemade phantom models were also examined in the search for phantom models.[5],[6],[7] However, although the materials used in these studies are cheap and easy to prepare, they do not meet the need for a phantom suitable for dentistry, as models that show anatomical structures that should be known especially for ultrasound indications in dental applications have not been made.

The aim of our study is to prepare a head–neck phantom model for ultrasound suitable for submandibular anatomy to be used in the education of research assistants in the department of radiology in dentistry, and to compare different materials for this purpose. The model is aimed to be practical, to be made with materials that can be found by every dentist, to be prepared with a low budget, and to be suitable for research assistant and student education.


   Materials and Methods Top


Our aim in this study is to make a submandibular phantom model that is easy to make, materials are cheap, and can mimic anatomical structures to learn how to use ultrasound in dentistry. The research was conducted in accordance with the principles of the World Medical Association Declaration of Helsinki Medical Research Ethics (as amended in October 2013), but this study was exempted from the review of the Human Research Ethics Committee because its methodology includes activities that do not involve human participants. All participants in the study gave their informed consent before inclusion in the study and participated in the study on a completely voluntary basis. The features sought with precision in the phantom model are that it can be reproduced and produced quickly in terms of being made by other physicians thereby contributing to education. To achieve these, we took care to select materials with the consistency and durability to imitate human tissue and then to provide alignment to reflect the anatomy of the submandibular region. To make our ultrasound phantom, we chose products that every dentist can find in stores, markets, and faculties. The purpose of this choice is to be made by everyone and to reduce the cost as much as possible. In the model, gelatin (ballistic gel), psyllium fibers, and agar solution were used to create the base layer, in which the anatomical structures would stand and mimic the organs and interstructural tissues optimally [Figure 1].
Figure 1: Gels to be used for soft tissue. (a) Ballistic gel, (b) Psyllium fibers, (c) agar

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In the literature review, all these materials were used separately in previous studies and were not compared.[6],[7],[8] In our study, we made use of the proportions in the studies and tried to choose the material that best suits the texture characteristics. We did not want to use color in the material that would fill the gap because we wanted to establish an instructive link between seeing the structures in the phantom model directly and seeing their counterpart on the ultrasound screen. We have obtained three different base materials by mixing psyllium fibers with gelatin and water,[6] obtaining agar solution,[9] and forming a ballistic gel[10] from gelatin. The mixing ratios were obtained by mixing 12 tablespoons of gelatin and four tablespoons of psyllium in 1 liter of hot water for psyllium, by boiling and cooling 3 grams of agar in 1 liter of water for agar, and by mixing one part animal gelatin in nine parts hot water for ballistic gel and cooling. After these three different materials were evaluated by two experienced maxillofacial radiologists in a way that their viscosity and ultrasonic appearance would be the most appropriate and tissue-like, the ballistic gel was decided to be used [Figure 2].
Figure 2: Ultrasound images of gels to be used for soft tissue. (a) Ballistic gel, (b) Psyllium fibers, (c) Agar

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After the selection of this tissue material, mandibular bone, digastric muscle, facial artery, submandibular salivary gland, submandibular ductus, and submandibular lymph nodes were simulated, although it could not show all the anatomical structures in the region due to technical difficulties to simulate the submandibular region. When we look at the echogenicity and image characters of these structures in ultrasonic images, we see that the bones are highly hyperechoic on the surface, the back is acoustic shadowed, the muscles are hypoechoic with hyperechoic myofasias, the blood vessels are anechoic with the hyperechoic lumen, the glands are in a homogeneous structure with moderate gray, and the lymph nodes are in a homogeneous structure. In accordance with these image characters, aluminum foil by the curvature of the mandible instead of the bone, spaghetti pasta to imitate the myofascial structure instead of the muscles, the parsley stalk and the balloon/glove surrounding them (can be wrapped with wax), water in a pleated pipette or tube of an infusion system instead of blood vessels, ketchup/mayonnaise/honey (in a small balloon) instead of gland structures, and small balloons filled with water or mayonnaise with a tube of an infusion system or pipette attached to the mouth instead of lymph nodes were selected by two experienced radiologists according to their correct appearance [Figure 3] and [Figure 4]. The prices of all these materials used are given in [Table 1].
Figure 3: Materials to be used for different tissues. (a) Plastic box, (b) Agar, (c) Psyllium fibers, (d) Animal gelatin, (e) Serum tube, (j) Balloons, (k) Aluminum foil in mandible form, (l) Spaghetti, (m) Ketchup and mayonnaise, (n) honey

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Figure 4: Positioning the prepared materials in the box

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Table 1: Materials used in the study and their prices

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MyLab Twice (Esaote, Genova, Italy) ultrasound device was used together with the LA523/13-4 Mhz linear array transducer probe to scan our phantom models.


   Results Top


Among the ballistic gel, agar solution, and psyllium fiber solutions that were tried to mimic human soft tissue and preserve it in their anatomical formations, ballistic gel was used instead of soft tissue in the phantom because it gives the most appropriate and the closest ultrasonographic image to the tissue [Figure 2]. After deciding on the soft tissue, an aluminum foil mandible form, which gives a hyperechoic contour appearance for the mandibular bone and leaves an acoustic shadow behind it, was tried, and when it was found to be suitable, no other material was tried. The handmade wooden mandible or a thick plastic that was planned to be tried instead of the mandibular bone was not tried because it was difficult to make and manipulate. After selecting the mandible and soft tissue, other materials were tested one by one until the most suitable ones were found for the surrounding structure to be simulated [Figure 5] and [Table 2].
Figure 5: Ultrasonographic imaging for the selection of suitable materials

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Table 2: Echogenicity of the materials tested

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After the examinations, it was decided to include aluminum foil for the bone, spaghetti and ketchup in a balloon for the muscle, mayonnaise in small balloons for the lymph nodes, ketchup in the balloon for the submandibular gland, and a tube of an infusion system for the facial artery and gland ductus [Figure 6].
Figure 6: Sonographic images of suitable materials. (a) Submandibular gland, (b) Digastric muscle, (c) Lymph nodes, (d) Mandibular body, (e) Facial artery)

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   Discussion Top


The use of ultrasound in dentistry is increasing, especially as seen in recent studies.[1],[2],[11],[12]

Uses of ultrasound in dentistry include periodontal applications,[13] bone level evaluation,[14],[15] endodontic imaging and therapeutic applications,[16],[17],[18] foreign body imaging,[19] mental foramen localization,[20] detection of malignant formations,[21] lingual artery, salivary glands and tongue imaging,[2],[11] TMJ, fracture and muscle imaging[22] and can be shown as sample. Therefore, ultrasound is a useful diagnostic and treatment tool in all dental specialties for imaging and treatment of both hard and soft tissues.

Integrating ultrasound into dental residency training enables assistants to better understand the maxillofacial anatomy, learn the clinical application areas of maxillofacial ultrasound, and improve clinical interpretation skills. The inclusion of ultrasound in the dental residency curriculum to teach anatomy can provide valuable information about interprofessional training experiences for residents. Therefore, this study aims to enable dentistry residents to apply ultrasound techniques and to design a cost-effective educational phantom model that can be reused in different institutions in ultrasound education.

Designing phantom models in ultrasound education has been tried and researched with ongoing studies since previous years.[23],[24] Inexpensive tissue-like ultrasound phantom models, which Bude et al.[23] tried nearly 20 years ago, continue to be tested even in recent years, with studies such as Sullivan et al.[7] after the research of Kendall et al.[25] and Mark D Lo et al.[6] When the studies and phantom models are examined, there is no design specific to dentistry. In the literature, percutaneous liver biopsy,[26] lumbosacral spine,[27] pericardiocentesis,[5],[7],[8] obstetric ultrasound,[28] soft tissue abscesses[6],[29] were examined, and phantom models were made. It is the first in this field of study as a phantom model has not been made for the use of ultrasound in dentistry before.

With the widespread use of ultrasound in Turkey, ultrasound education has become inevitable and necessary in dentistry faculties. When we look at the traditional education and training plans, we see that before the medical devices and instruments are used on the patient, it is necessary to work with a model or with practical exercises (simple drawings, experiments on different materials) and gain the necessary experience. When we look at the phantom models currently on the market for this pre-clinical education, we see no model that shows anatomical structures to exercise in the head–neck region and submandibular region. Two companies stand out in the market; but when we look at the models in these online sites, we see that there are thyroid examination phantom closest to the head and neck in CIRS, and the closest artery–vein and thyroid examination models in Bluephantom.[3],[4]

Although the materials used in the study are similar to the materials in the previous studies, they were rearranged in a simpler and home environment. Although there are standard sizes and materials[10],[30] for professional use in ballistic gel production, only animal gelatin was used in this study as we think it is sufficient for the use of phantom models. While trying to create soft tissue with psyllium fibers, the measurements of Sullivan et al.[7] and Mark d lo et al.[6] were used, but the ballistic gel was preferred primarily because of its strength and suitability for soft tissue echogenicity. Besides, in the model using psyllium fibers, the fibers collapsed down and formed different images, and soft tissue echogenicity was not captured in agar solution.

Mohr et al.[29] also worked with pudding, but it was not preferred in this study because it is organic and perishable.

Previous studies have used cadavers,[31] piglets,[28] or animal meat,[26],[32] but these have several limitations. First of all, procurement of cadavers in dentistry is very difficult in terms of financial difficulties, preservation, and practicality. However, the cadaver study was not conducted because the aim of the study was convenience and it was far from being simply available in every institution.

Our phantom model also has some limitations to talk about. Firstly, we think that products such as pasta, ketchup, mayonnaise, among the materials used, will slowly deteriorate and rot because they are organic. However, no deterioration was noted during the 2 weeks, which was the period of our work on the model. When this deterioration will occur can be determined in long-term follow-up studies. Secondly, an assistant is required when placing materials that mimic the anatomical formations into the gel materials and it is difficult to keep them in the desired position since the gel does not solidify yet. Finally, although we work meticulously in structures such as salivary glands and lymph nodes prepared in the balloon, we encountered air bubbles that will affect the image minimally.


   Conclusions Top


The submandibular region phantom can be a useful tool to learn the sonoanatomy of the head, neck, and submandibular region and to improve the ability to use ultrasound. The advantage of this model is that it uses materials available to any dentist, is easy to prepare and apply, and can be used over and over again. These advantages will make an important contribution to ultrasound learning in dentistry. To show the effectiveness and validity of our phantom model, we think that it is necessary to look at the long-term-use results and to use it more frequently in educational studies.

Author contribution

Gediz Geduk carried out the writing of the article and the experiments.

Şükriye Ece Geduk worked in the experiments and materials phase of the article.

Çiğdem Şeker worked on the literature search and method part of the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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

  [Table 1], [Table 2]



 

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