Dental Radiology 3nd stage

Lec.7 ‫ ﺣ ﻮ ر اء اﻟ ﺨ ﺰ اﻋ ﻲ‬. ‫د‬

Introduction

Extraoral radiography is defined as examination of the head and facial region using films located
outside the mouth. They allow the dentist to view large areas of the jaws and skull on a single
radiograph not covered by intraoral films. It is also useful when patients are unable to open their
mouths for film placement. Extraoral radiographs do not show the details as well as intraoral films.
Extraoral radiographs are not adequate for detection of subtle changes such as the early stages of dental
caries or periodontal disease. There are many types of extraoral radiographs, some types are used to
view the entire skull, where as other types focus on the maxilla and mandible.

Skull views

True lateral skull

This projection shows the skull vault and facial skeleton from the lateral aspects. This is used when a
single lateral view of the skull is required not in orthodontics or growth studies. The image receptor is
positioned parallel to the patient's midsagittal plane. The site of interest is placed toward the image
receptor to minimize distortion. The film is adjusted so that the upper circumference of the skull is half
inch below the upper border of the cassette. The central ray is directed perpendicular to the cassette and
the midsagittal plane and towards the external auditory meatus.

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Indications:

v Fractures of the cranium and the cranial base.

v Middle third facial fractures, to show possible downward and backward displacement of
maxilla.
v Investigation of the frontal, sphenoidal and maxillary sinuses.
v Condition affecting the skull vault:
1- Paget's disease 2- Multiple myeloma 3- hyperparathyroidism 4- Conditions affecting the sella
turcica, as tumor of pituitary gland in acromegaly

Postero-anterior of the skull (PA skull)

This projection shows the skull vault, primarily the frontal bones and the jaws. The image receptor is
placed in front of the patient, perpendicular to the mid sagittal plane and parallel to coronal plan, so
that the canthomeatal line is perpendicular to the image receptor. Central ray is directed at right angles
to the film through the mid sagittal plane through the occipit.

Indications:

Fractures of the skull vault. Investigation of the frontal sinus. Conditions affecting the cranium:

1- Paget's disease 2- Multiple myeloma 3- hyperparathyroidism 4- Intracranial calcifications

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Anatomical landmarks in PA projection

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Towne's view (anteroposterior view)

Observe occipital area of skull. Neck of condylar process. Film position- cassette perpendicular to
floor, Long axis-vertically. Position of patient- back of patients head touching film. Canthomeatal line
perpendicular to film. Central ray 30 degree to canthomeatal line and passes it at a point between
external auditory meatus. It is primarily used to observe the occipital area of skull.

Submento-vertex (SMV)

This projection shows the base of the skull, sphenoidal Sinuses and facial skeleton from below. The
image receptor is positioned parallel to patient's transverse plane and perpendicular to the mid sagittal
and coronal planes. To achieve this, the patient's neck is extended as far backward as possible, beam is
perpendicular to the image receptor, directed from below the mandible toward the vertex of the skull,
and centered about 2 cm anterior to a line connecting the right and left condyles.

The indications:

v Destructive/ expansive lesions affecting the palate, pterygoid region or base of skull.
v Investigation of the sphenoid sinus.
v Assessment of the thickness (medio-lateral) of the posterior part of the mandible before
osteotomy.
v Fracture of the zygomatic arches, to show these thin bones the SMV is taken with reduced
exposure factors (Jug handle view).

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Projections for mandible

Two views for mandibular projection:
1- Lateral oblique projection

a. Mandibular Body Projection: for demonstration premolar-molar region and inferior border of
the body of the mandible. Head tilted to the side to be examined with the mandible protruded. Film is
placed against the patient's cheek and centered over the first molar. The lower border of the cassette
should be parallel to the inferior border of the mandible and at least 2cm below it. The X-ray tube 2cm
below angle of the mandible directed toward the first molar region of cassette side.

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b. Mandibular Ramus Projection: to view the ramus from the mandibular angle to the condyle for
examining the third molar region of both the maxilla and mandible. Head tilted towards the projected
mandible. Film is placed over the ramus of the mandible to the far posterior to include the condyle.
Lower border of the cassette 2cm below the inferior border of the mandible. The tube 2cm below the
inferior border of the first molar region on the tube side toward the center of the ramus on the cassette
side.

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Indications: 1 – Position of impacted third molars 2– Fractures of the ramus,

condyle, or body of the mandible (but not symphysis)

2- Postero-anterior of the jaws (PA jaws or PA mandible)

This projection shows the posterior parts of the mandible. It is not suitable for showing the facial
skeleton because of superimposition of the base of the skull and the nasal bones.

The indications:

• Fractures of the mandible involving the following sites:

1- Posterior third of the body 2- Angles 3- Rami 4- Low condylar neck
• Lesions such as cysts or tumors in the posterior third of the body or rami to note any medio-
lateral expansion
• Mandibular hypoplasia or hyperplasia
• Maxillofacial deformities
The cassette is placed in front of the patient, so that the median sagittal plane should be perpendicular
to the cassette. The head is then adjusted to bring the orbito-meatal baseline perpendicular to the
cassette. The cassette should be positioned such that the middle of cassette, is centered at the level of

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the angles of the mandible. The central ray is directed perpendicular to the cassette and centered in the
midline at the levels of the angles of the mandible.

Standard occipitomental

This projection shows the facial skeleton and maxillary anrta., and avoid superimposition of the dense
bones of the base of the skull.

Indications:

1. Middle third facial fracture

2. Coronoid process fracture
3. Maxillary, Ethmoidal and Frontal sinuses.
The patient is positioned facing the film with the head tipped back
so the radiographic baseline is at 45 degree onto the film, the so-
called nose-chin position. This positioning drops the dense of the
base of the skull downwards and raises the facial bones so they can
be seen. The x-ray tube head is positioned with the central ray
horizontal (0 degree) centered through the occipit.

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 Dental Radiology 3nd stage

30-degree occipitomental (30-degree OM)

This projection also shows the facial skeleton, but from a different angle from the 0oOM, enabling
certain bony displacements to be detected.

The main clinical indications include:

1- Middle third facial facture 2- Coronoid process fracture 3- Maxillary and frontal sinuses

The patient is in exactly the same position as for the zero-degree OM, the head tipped back,
radiographic baseline at 45 degree to the film, in the nose-chin position. The ray- tube head is aimed
downwards from above the head, with the central ray at 30o to the horizontal, centered through the
lower border of the orbit.

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PA Water's view

The image receptor is placed in front of the patient and perpendicular to the mid sagittal plane. The
patient's head is tilted upward so that the canthomeatal line forms a 37degree angle with the image
receptor. If the patient's mouth open, the sphenoid sinus will be seen superimposed over the palate. The
central beam is perpendicular to the image receptor and centered in the area of maxillary sinuses.

Indications

1– Evaluation of the maxillary sinus 2– Evaluation of the frontal sinus 3– View of orbit and nasal
fossa

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Caldwell's modification: Caldwell's view (or Occipitofrontal view)

is a radiographic view of skull where the X-rays is angled 20 degree to orbitomeatal line which is
perpendicular to radiographic plate. It is commonly used to get better view of frontal sinuses. The
patient's forehead is placed against the image detector, petrous ridge is below orbits, image size: 24 x
30 cm. The beam travels posterior to anterior (PA) direction, angulated by 15-20 degrees, 80-85 kVp at
25 mAs. Structures seen:

frontal sinus, ethmoidal sinus, orbital rim, medial orbital wall, zygomatic bone, nasal bone, nasal
septum, and mandible.

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 Dental Radiology 3nd stage
con. Extraoral radiography ‫ ﺣوراء اﻟﺧزاﻋﻲ‬.‫د‬

Introduction

The tempromandibular joint is one of the most difficult area to investigate radiographically. This fact is
underlined by the many types of investigations that have been developed over the years. Several plain
radiographic projections and the modern imaging modalities are used for showing different parts of the complex
joint anatomy.

Sagittal view coronal view

In TMJ Radiography, we should be able to identify:

• External auditory meatus of the ear. • Articular eminence.

• Articular fossa. • Mandibular condyle. • The neck of condyle.

The articular disk appears radiolucent so it can be seen by specialized imaging techniques.

Pathological lesions of TMJ which seen by radiographs

• Fractures • Benign and malignant tumor • Arthritic changes • Ankylosis • Disk displacement and
perforation • Hypertrophy and osteolytic changes in condyle.

Diagnostic imaging of the tempromandibular joint

To provide as much diagnostic information as possible about the joints, a wide range of investigations has been
developed. These can be subdivided into:

1- Conventional radiographic projections 2- Other techniques and investigations.

The choice of imaging technique will depend on: the specific clinical problem, whether hard or soft tissues
will be imaged, radiation dose, cost, availability of the imaging technique, and the amount of diagnostic
information provided by the technique. There have been considerable advances in imaging technology to reduce
radiation dose and availability of imaging continues to improve.

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Conventional radiographic projections

1) Panoramic projection. 2)Transcranial projection. 3)Transpharyngeal projection.

4) Transorbital projection. 5) Reverse Towne's projection. 6) Submentovertex projection.

7) Conventional tomography.

1-Panoramic projection

The panoramic projection is often included as part of the examination because it provides an overall view of the
teeth and jaws, provides a means of comparing left and right sides of the mandible, and serves as a screening
projection to identify odontogenic diseases and other disorders that may be the source of TMJ symptoms. Gross
osseous changes in the condyles may be identified such as asymmetries, extensive erosions, large osteophytes,
tumors or fractures. The panoramic view should not be used as the sole imaging modality and should be
supplemented.

Panoramic image with right condylar hyperplasia Panoramic image with malignant tumor in the condyle

2-Transcranial projection

The transcranial view provides a sagittal view of the joint. The radiographs are taken of both right and left side
in both the open and the closed position. The transcranial view can be used to examine the joint for fracture with
marked dislocation and for gross arthritic changes, particularly in the lateral part of the joint.

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3-Transpharyngeal projection

This projection depicts the medial aspect of the condyle and is taken with mouth open only. This view is
effective for demonstrating destructive changes of the condyle but less valuable for productive changes, it may
also be of value for diagnosis of condylar neck fractures, but information about the temporal component of the
joint is not available.

4-Transorbital projection

This projection provides an anterior view of the TMJ, perpendicular to transcranial and transpharyngeal
projections. X- ray beam is directed from the front of the patient through the ipsilateral orbit and TMJ of
interest. The patient opens the mouth maximally to position the condyle at the sum with the articular eminence
and avoiding superimposition of the articular eminence on the condyle. This view is useful for visualize the
condyle fractures.

5-Reverse Towne's projection

This projection shows the condylar heads and necks.

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Submentovertex (baseler) projection

This view is useful for viewing condyles, zygomatic arch, lateral wall of the orbit, sphenoid and maxillary
sinuses and pterygoid plates and the structures of the base of the skull. A submentovertex (basal) view may
be used to determine the angulations of the condylar head long axes in order to “correct” the angulation of
the tomographic images.

Conventional tomography

Imaging of the TMJ itself is best accomplished by the use of tomography, which has the advantage of depicting
the TMJs in thin layers or slice increments. The film and x-ray source are in motion, which blurs structures that
are not in a predetermined plane of focus. The joints can be imaged in different orientations, achieving the aim
of producing views perpendicular to each other. Normally, several image slices in the sagittal (lateral) and coronal
(frontal) plane are made. Sagittal images provide information on condylar position with respect to the glenoid
fossa and can be taken at various mandibular positions. Most commonly, sagittal views are exposed with the teeth
in the closed (maximum intercuspation) and maximum open positions.

Other techniques and investigations

1) Computed tomography
a) Conventional, medical CT
b) Cone-beam CT
2) Magnetic Resonance imaging
3) Arthrography
4) Ultrasonography

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 Dental Radiology 3nd stage

Introduction
Panoramic imaging is a standard procedure to survey the whole dental status. It shows a two-
dimensional view of a half-circle from ear to ear. Panoramic radiography is a form of
tomography; thus, images of multiple planes are taken to make up the panoramic image. In
panoramic imaging the patient’s jaws and facial bones are scanned with a narrow x-ray beam,
which rotates around the patient producing a sharp image layer.

(Focal trough)

A panoramic image shows a curved layer of the jaws including tempromandibular joints (TMJ).
Panoramic x-ray devices produce a wide range of two-dimensional clinical views e.g. adult pan,
pediatric pan, TMJs, segments (partial panoramic view of a selected region in the dentition),
sinuses, bitewing.
In panoramic imaging, the patient's dental arch must be positioned within a narrow zone of sharp
focus known as image layer. The image layer is a three-dimensional curved zone, or "focal
trough" where the structures lying within this layer are reasonably well defined on final
panoramic image. Objects outside the image layer are blurred, magnified or reduced in size and
are sometimes distorted to the extent of not being recognizable.

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 Dental Radiology 3nd stage

Composition of panoramic radiography equipment

Dental panoramic radiography equipment consists of a horizontal rotating arm which holds an
X-ray source and a moving film mechanism (carrying a film) arranged at opposite side. The
patient's skull sits between the X-ray generator and the film. The X-ray source is collimated
toward the film, to give a beam shaped as a vertical blade having a width of 4-7mm when arriving
on the film, after crossing the patient's skull. Also, the height of that beam covers the mandibles
and the maxilla regions. The arm moves and its movement may be described as a rotation around
an instant center which shifts on a dedicated trajectory.
The manufacturers propose different solutions for moving the arm, trying to maintain constant
distance between the teeth to the film and generator. Also, those moving solutions try to project
the teeth arch as orthogonally as possible. It is impossible to select an ideal movement as the
anatomy varies very much from person to person. Finally, a compromise is selected by each
manufacturer and results in magnification factors which vary strongly along the film (15%-30%).
The patient positioning is very critical in regard to both sharpness and distortions. Normally, the
person bite on a plastic spatula so that all the teeth, especially the crowns can be viewed
individually. The whole orthopantomogram process takes about one minute. The patient’s actual
radiation exposure time varies between 5.5 to 22 seconds.

Patient positioning

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To obtain diagnostically useful panoramic radiographs, it is necessary to properly prepare
patients and to position their heads carefully in the image layer. Persons who are to undergo
panoramic radiography usually are required to remove any earrings, jewellery, hair pins, glasses,
dentures or orthodontic appliances. If these articles are not removed, they may create artifacts
on the image (especially if they contain metal) and reduce its usefulness. There is also a need for
the person to stay absolutely still during the 18 or so second cycle it takes for the machine to
expose the film. For this reason, radiographers often explain to the person beforehand how the
machine will move.

Types of panoramic radiography equipment

There are two kinds of film moving mechanisms, one using a sliding flat cassette which holds
the film, and another using a rotating cylinder around which the film is wound. There are two
standard sizes for dental panoramic films: 30 cm × 12 cm and 30 cm x 15 cm. The smaller size
film receives 8% less X-ray dosage on it compared to the bigger size.
Dental X-rays' radiology is moving from film technology (involving a chemical developing
process) to digital X-ray technology, which is based on electronic sensors and computers. One of
the principal advantages compared to film based systems is the much greater exposure latitude.
This means many fewer repeated scans, which reduces costs and also reduces patient exposure
to radiation. Lost X-ray can also be reprinted if the digital file is saved. Other significant
advantages include instantly viewable images, the ability to enhance images, the ability to email
images to practitioners and clients, no darkroom required and that no chemicals are used.

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Panoramic images are valuable diagnostic tools in these clinical tasks
• Impacted wisdom teeth diagnosis and treatment planning

• Periodontal bone loss and periapical involvement.

• Assessment for the placement of dental implants
• Orthodontic assessment. pre and postoperative
• Diagnosis of developmental anomalies such as cherubism, cleidocranial dysplasia
• Carcinoma in relation to the jaws
• Temporomandibular joint dysfunctions and ankylosis.
• Diagnosis, and pre- and post-surgical assessment of oral and maxillofacial trauma, e.g.
dentoalveolar fractures and mandibular fractures.
• Other diagnostic and treatment applications.

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Panoramic radiography by far is a very popular and widely accepted technique. A part from the
routine uses, it is also used for dimensional and angular measurements. One of the shortcomings
of panoramic radiographs is image distortion. Magnification or distortion is an inherent property
of panoramic machine. The position of an object between the x-ray source and the film is
responsible for magnification seen on radiograph.

Principal advantage of panoramic radiography

• Broad coverage of facial bones and teeth

• Low patient radiation dose
• Convenience of examination for the patient (films need not be placed inside the mouth)
• Ability to be used in patients who cannot open the mouth or when the opening is restricted
e.g.: due to trismus
• Short time required for making the image
• Patient's ready understandability of panoramic films, making them a useful visual aid in
patient education and case presentation.
• Easy to store compared to the large set of intra oral x-rays which are typically used.

Disadvantages

1. The resultant image does not resolve the fine anatomical structures (caries, periodontal
disease)
2. There is also some magnification and overlapped images of teeth in the molar region,
however the angular relationships are accurate.
3. The cost of a panoramic x-ray machine is 2-4 times the cost of an intraoral machine.