Oral Radiology

Extra-oral
Radiography

OMD-361
LECTURE ILOs

• Explain the principles of extraoral radiographic techniques

• Understand extraoral indications
• Recognize, identify, and list anatomical landmarks related to various extra-
oral radiographs
These are the radiographic techniques:

In which the film is placed outside the oral cavity.

Either against the side of the face to be radiographed or
nearby.
And the x-ray beam is directed toward it.
Extra oral radiographs provide images of larger areas
such as the skull and jaws.
However, images seen on an extra oral film are not as
clear or as well defined as the images seen on an
intraoral radiograph.
 Indications of Extra Oral
Radiographs
Fractures of the skull & face.
Lesions or conditions affecting the skull &
face.
Assessment of salivary glands, Sinuses or
TMJ joint.
As an alternative to intraoral views
(because of severe gagging or if the patient
is unable to open his mouth or is
unconscious).
Drawbacks of Extra Oral Techniques

 Magnification occurs due to the greater object

to film distance used.
 Details are not well defined.
 Contrast is reduced as the secondary radiation
produced by the soft tissues is more.
 It is a 2- D image of 3- D structure.
Definitions of Some Extra-oral Landmarks used for
Patient Positioning
The Main Anatomic Landmarks Used In
Patient Positioning

Midsagittal plane Frankfort plane

The canthomeatal line: (orbitomeatal line) (radiographic baseline)

A line representing the base of the skull.

It is the main anatomic landmark used in patient
positioning during extraoral radiography.
It joins the central point of the external auditory canal to
the outer canthus of the eye.
CANTHOMEATAL LINE
THE FRANKFORT PLANE:

Is the line that connects the

superior border of the external
auditory canal with the
infraorbital rim.
THE MIDSAGITTAL PLANE:

Is an imaginary line extending from the interproximal

space of the maxillary central incisors through the nasal
septum .

It also extends through the middle of the foramen

magnum and the posterior arch of the atlas.
 X-ray Machine
May be:
Intraoral: May be used for extra oral
films but not recommended.
Pan/Ceph: Standard for orthodontics &
oral surgery.
Extra oral / Specialty: Rotating anode;
because of high mA, long exposure.
Intraoral Pan/Ceph
Specialty Extra Oral Machine

Indirect film / Cassette

EXTRA-ORAL RADIOGRAPHY
A device used to decrease film fog and increase the
contrast of the radiographic image.

Grid
It does this by reducing the amount of scatter
radiation that reaches an extraoral film during
exposure.
Extra-oral Radiographic Examinations Can Be Divided
Into:

1- Lateral views:

a. Lateral oblique projections of the mandibular body
b. Lateral oblique projections of the mandibular ramus
c. True lateral and lateral cephalometric projection
 Extra-oral Radiographic Examinations Can Be Diveded Into:

2. Posteroanterior views: (the central beam is directed from the posterior to

the anterior)
a. Posteroanterior skull projection and posteroanterior cephalometric
projection
b. Waters projection (Occipitomental projection)
c. Reverse Towne projection
Extra-oral Radiographic Examinations Can Be Divided Into:

3.Antroposterior views: (the central beam is directed from the anterior to

the posterior)

a. Submentovertex projection

 Lateral Jaw Projection
(Lateral Oblique Projection)
Uses:
Used to view the posterior region of the
mandible.

Fractures of the mandible, in combination with

occlusal radiographs.

Impacted teeth.

Full extent of pathological conditions.

Indications:
 Children

 Patients with a limited jaw opening

due to fracture or swelling

 Patients who cannot tolerate

intraoral film placement.

The lateral jaw projection can be

taken with a standard x-ray unit.
 Lateral Jaw Projection
Techniques

Body of Ramus of
mandible mandible
projection. projection.
 :Body Of Mandible Projection
Demonstrate:

• Mandibular premolar & molar

regions.
• Inferior border of the mandible.
Evaluate:
• Impacted teeth.
• Fractures.
• Lesions at the body of the mandible.
 Ramus Of Mandible Projection
Demonstrate:
• The view of the ramus from the angle of
the mandible to the condyle.
Evaluate:
• Impacted third molars.
• Large lesions.
• Fractures that extend into the ramus of
the mandible.
 Film placement
The cassette is placed flat against the patient
cheek:
In the body of mandible projection: Centered
over the body of the mandible & positioned
parallel with it.
In ramus of mandible projection: Centered over
the ramus of the mandible & positioned parallel
with it.
 Film Placement
In both projections:

The patient must hold

the cassette in position
with the thumb under
the edge of the cassette
and the palm against the
outer surface of the
cassette.
 Head Position
 The head tipped about 15 degrees
towards the side being imaged (to avoid
superimposition of the other side on the
area of interest).
 The chin is extended & elevated
slightly (to avoid superimposition of
hyoid bone on the mandible).
 Beam Alignment
In the body of mandible projection:
• The central ray is directed to a point
just below the inferior border of the
mandible on the side opposite the
cassette.
• The beam is directed upwards (-15 to -
20) ,centered on the body of the
mandible & perpendicular to the film.
 Beam alignment (cont.)
In Ramus of Mandible Projection:
• The central ray is directed to a point
posterior to the third molar region on
the side opposite the cassette.

• The beam is directed upwards (-15 to

-20) ,centered on the ramus of the
mandible & perpendicular to the film.
-
 1
2

1. Articular eminence. 2. Zygomatic arch.

 Skull
Radiography
 Skull radiography is used to examine the
bones of the face and the skull.
 Indications:
 Orthodontics.
 Oral surgery.

 Some skull films can be exposed using a

standard x-ray machine, however, most requires
the use of an extra oral unit and cephalostat.
 Types
1. True lateral skull.
2. True postero-anterior.
3. Occipito-mental(Water’s View).
4. Reverse Towne’s.
5. Submento-vertex.
6. Lateral TMJ radiograph:
a. Transcranial
b. Transpharyngeal
c. Transorbital
True Lateral Skull
(Dead Lateral)
This projection shows:
• The skull vault.

• The facial skeleton

from the lateral aspect.
Indications:
Used when a single lateral view of the skull is
required but NOT in orthodontics or growth
studies. It’s indicated in:
 Fractures of the cranium & the cranial base.
 Middle third facial fractures (shows downward
& backward displacement of the maxilla).
 Examination of frontal , sphenoidal and
maxillary sinuses.
Conditions affecting skull vault, as:
 Paget`s disease.
 Multiple myeloma.
 Hyperparathyroidism.

 Conditions affecting the sella turcica, such as

tumor in the pituitary gland in acromegaly.
 Technique & Positioning
 The patient is positioned in a manner
so that the side of the face touches
the film, i.e: the sagittal plane of the
head is parallel to the film.
 The x-ray tube head is positioned with
the central ray is perpendicular to the
mid-sagittal plane and the film,
centered to the external auditory
meatus.
MSP MSP

Extraoral X-ray
Unit
Floor Film Horizontal
 Postero-anterior View
Indications:
1. Fractures of body,
angle & ramus of
the mandible
2. Alveolar fractures.
3. Neck and head of
condyles.
 Postero-anterior View
Indications:
1. Fractures of the skull vault
2. Investigation of the frontal sinuses
3. Conditions affecting the cranium,
particularly:
 Paget's disease
 multiple myeloma
 hyperparathyroidism
Main indications
4. Intracranial calcification
5. Fractures of the mandible involving the following
sites:
 Posterior third of the body
Angles
Rami
Low condylar necks
.
Main indications
6. Lesions such as cysts or tumors in the Posterior third
of the body or rami to note any
Medio-lateral expansion

7. Mandibular hypoplasia or hyperplasia

8. Maxillofacial deformities
 Technique and Positioning
The patient is positioned facing the film and:
 The head tipped forward so that the
forehead & tip of the nose touch the film,
the so-called forehead-nose position.

 The radiographic baseline (Cantho-meatus Line)

is horizontal & at right angles to the film.

 
 This position allows the vault of the
skull to be seen without super-
imposition.

 The X-ray tube head is positioned

with the central ray centered
through the occiput.
 
 Frontal Sinus

Etmoidal Air Cell

Orbit
Middle Nasal Meatus Maxillary Sinus Area
Inferior Nasal Turbinate
Coronoid
Process
Subcondylar Fracture
Zygomatic Process
Of Maxilla
Nasal Septum
 Occipito-mental View
Waters’ View( (
Indications:
1. Investigation of the maxillary antra
2. Detecting the following middle third facial
fractures:
— LeFort I
— Le Fort II
— Le Fort III
— Zygomatic complex
— Naso-ethmoidal complex
— Orbital blow-out
Indications:
3. Coronoid process fractures
4. Investigation of the frontal and ethmoidal sinuses
5. Investigation of the sphenoidal sinus
 Technique and Positioning
 The head tipped back so the radiographic
baseline is at 45º to the film.
 This positioning drops the dense bones of the
base of the skull downwards & raises the facial
bones so they can be seen.
 The central ray is horizontal & centered
through the occiput.
 Frontal sinus Water’s

Orbital rim Ethmoid

sinus
Zygomatic
arch
Air-fluid level
Inferior
Maxillary border of
mandible
sinus

Lateral wall
of the nasal
cavity

Nasal septum Hyoid

C-spine bone
 Frontal
Sinus
Zygomatico-
frontal Suture Sphenoid
Sinus
Zygomatic
Maxillary Sinus
Arch

Coronoid
Zygomatic
Process
Bone

Inferior
border of
Occipital mandible
Bone
 Reverse Townes View
Indications:

1)Examination of the
condylar head.

2)Fractures of neck of
condyles.
Indications:
1.High fractures of the condylar necks

2.Investigation of the quality of the articular surfaces of

the condylar heads in TMJ disorders

3. Condylar hypoplasia or hyperplasia

 Technique and Positioning
 The head tipped forwards in the forehead-
nose position, but in addition the mouth is
open.

 The radi­ographic baseline is horizontal and at

right angles to the film.

 Opening the mouth takes the condylar heads

out of the glenoid fossae, so they can be
seen.
 the X-ray beam is aimed upwards at 30°.
 Submentovertex View
Indications:
1) Fractures of the zygomatic arches.

2) Base of the skull.

3) Destructive lesions affecting the

palate, or base of skull.
 Technique and Positioning
 The head is tipped backwards as far
as is possible, so the vertex of the
skull touches the film.

 In this position the radiographic

baseline is vertical and parallel to the
film.
 The X-ray tube head is aimed upwards from
below the chin, centered on an imaginary line
joining the lower first molars.

 Note:
The head positioning required for this projection
is contraindicated in patients with suspected
neck injuries
Central
Ray
 Nasal
Mandible septum

Foramen
Ovale
Mandibular
Foramen condyle
Spinosum

Foramen
Magnum
 Zygomatic Arch View

Reduce exposure to 1/3 setting

Cephalometric
Radiography
Cephalometric radiograph is a standardized & a
reproducible form of skull radiography.

Standardization resulted due to the

development of cephalometry.

The measurement & comparison of specific

points, distances and lines within the facial
skeleton is now an integral part of orthodontic
assessment.
uses
1) Assessment of the facial
skeleton
2) Relationship of the jaw
bases
3) Relationship of the axial
inclination of incisors
4) Assessment of the soft
tissue morphology
5) Growth pattern and
direction
6) Localization of the
malocclusion
7) Treatment possibilities
and limitations.
Equipment:
Several different types of equipment are available for
Cephalometric radiography, either as a separate unit or
as additional attachment to dental panoramic units.

1. Cephalostat (Craniostat).
2. X-ray generating apparatus.
Cephalostat
1-Head positioning and stabilizing apparatus:
 Made of two long arms enclosing the head of the
patient; they are usually made of plastic and can
be adjusted to different widths of head.
 The head is fixed by means of two small,
horizontal pegs at the end of the localizing arms,
which are introduced into the external auditory
meatus.
 Usually, these pegs include some metal to
determine the accuracy of this technique.
2- Cassette holder, including:
A- Cassette:
 Usually 18 x 24 cm.
 Containing intensifying screens and indirect-
action film.

B- Aluminum wedge filter:

This is either attached to the cephalostat and
positioned between the patient and the anterior
part of the cassette, or attached to the tube head
covering the anterior part of the emerging beam.
Its function is to:
 Attenuate the x-rays reaching the anterior
portion of the image.

 This allow the soft tissue outline of the face

(which are less dense than facial bones thus
needs less x-ray radiation) to be seen in the
radiograph.
Head Positioner/Film Holder

Head Positioner
Cassette
Holder
 Technique and Positioning
The patient is positioned within the
cephalostat:
• The sagittal plane of the head is vertical
& parallel to the film.
• The Frankfort plane horizontal.
• The teeth should be in maximum
intercuspation.
 Technique and Positioning

• The head is immobilized with the

plastic ear rods being inserted
gradually into the external auditory
meati.
There are two Main radiographic
projections:

1) True Cephalometric lateral skull.

2) Cephalometric postero-anterior of
the jaws (PA jaws).
True Cephalometric lateral skull
 Lateral
True Lateral
Cephalometric
 Roof of
Sella Turcica Ethmoid the Orbit Frontal
Sinus 4
Bone
Frontal
Sinus

Nasal
Sphenoid Bone
1
Sinus Orbit

Ant Nasal
Pharyngeal
Spine
Space

Soft Palate Hard Palate

Hyoid
Bone

Inferior border Maxillary

of the Mandible Sinus
 Film parallel Canthomeatal Canthomeatal Canthomeatal Canthomeatal
Patient to midsagittal line line line line
Placement Plane parallel to film at 37° with film at 10° with film at –30° with film

Beam Beam Beam Beam Beam

Central perpendicular perpendicular perpendicular perpendicular perpendicular
Beam to film to film to film to film to film

Diagram
LATERAL CEPH SMV WATERS PA CEPH REVERSE TOWNE
of patient
Placement

Illustration
of patient
Placement

Skull view

Resultant
image