Université de Yaoundé 1

Faculté de Médecine et des Sciences Biomédicales

Conventional Radiography in
Maxillofacial region

Dr Taal Bernard K.
SP1- Oral and Maxillofacial Surgery
 Objective
General objective
• Understand the different techniques use in conventional radiography

Specific objectives
1. List the different conventional radiographic techniques use in
Maxillofacial region
2. Give the indications of each techniques
3. Describe the different techniques
4. Interpret the different x-ray films
2
 Conventional Radiography in Maxillofacial
region

Plan

Introduction

1. Generalities

2. Techniques in Conventional Radiography

Conclusion

3
 Introduction (1/2)
• Radiography – techniques involved in producing the
radiographic images

• Radiology – interpretation of these radiographic images.

• W.C Roentgen - X-ray- in 1895, Nobel Prize in Physics in 1901.

• Conventional radiography- silver grain is randomly dispersed

in the emulsion.

4
 Introduction (2/2)
Conventional radiography can be divided into 2 groups

Intraoral – image receptor -placed inside the patient’s mouth:

• Periapical radiographs
• Bitewing radiographs
• Occlusal radiographs

 Extraoral – image receptor - placed outside the patient’s mouth:

• Oblique lateral radiographs
• All skull radiographs
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 1. Generalities (1/8)

Image

Two dimensional picture

• Black-radiolucent
• White- radiopaque
• Grey – partially stopped

Figure 1: Position of X-R Tube, patient and image receptor

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 1. Generalities (2/8)

Fig 2: Dental Xray machine and glass tube 7

 1. Generalities (3/8)
Image receptor- 2 types

1. Radiographic film
• Direct action or packet film
• Indirect action A outer wrapper. B film. C sheet of lead foil. D black paper.
Fig 3A : Packet film
2. Digital receptors
• Solid-state sensors
• Phosphor plates.
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Fig 3B – cross section of x-ray film
 1. Generalities (4/8)

Indirect-action film- Extraoral

projections,

• Requirements

An extraoral cassette containing film

Intensifying screens or a digital

phosphor plate

lead shield to cover half the cassette

Fig 4 : indirect film and cassette
when taking bimolar views. 9
 10
Fig 5 : Block Diagram of the x-ray
 1. Generalities (6/8)

Positioning image receptor, object and

X-ray beam

• object and image receptor –

contact or close together as possible
parallel to one another

• X-ray tubehead - right angle to both

object and image receptor
Fig 6: Patient position
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 1. Generalities (7/8)

Stage 1: Development
Stage 4: Washing
• sensitized silver halide crystals to
• remove residual fixer solution.
black metallic silver.

Stage 2: Washing Stage 5: Drying

• remove residual developer solution • resultant black/white/grey

Stage 3: Fixation radiograph is dried.
• Remove unsensitized silver halide
crystals 12
 1. Generalities (8/8)
Quality of the radiographic image

• Contrast – difference between the various black, white and grey

shadows

• Image geometry – the relative positions of the image receptor,

object and X-ray tubehead

• Characteristics of the X-ray beam

• Image sharpness and resolution.

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 2. Maxillofacial/skull projections(1/3)
Sagittal plan

Main projection Coronal plan

•S
1.PA skull - Crane de face

2. True lateral skull- crane de

Transverse pan
profil

3. Submentovertex (SMV)-
Crane axial Fig 7: Different facial plan
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PA= postero anteterior
 2. Maxillofacial/skull projections(2/3)
1.PA skull - Crane de face
• Reverse Towne’s
• Standard occipitomental (0° OM)
2. True lateral skull- crane de
• 45° OM- Blondeau
profil
• 55° OM- Waters

• PA jaws (mandible) • lateral oblique view

• AP skull Towne’s projection • Schuller’s projection

PA- posterioranterior;
3. Submentovertex (SMV)-
OM-occipitomental Crane axial (incidence de Hirtz )
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 2. Maxillofacial/skull projections(3/3)
Indication for Extraoral Radiograph

• Patients having trismus

• To examine the extent of lesions

• To evaluate trauma

• To evaluate impacted teeth

• To evaluate temporomandibular joint.

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 2.1 Posteroanterior skull (PA skull) (1/3)
This projection shows: skull vault, frontal bones jaws.

Main indications

• Investigation of the frontal sinuses

• Conditions affecting the cranium:

Paget’s disease of bone
Multiple myeloma
Hyperparathyroidism

• Intracranial calcification. 17
 2.1 Posteroanterior skull (2/3)
Technique and positioning

1. The patient is positioned A

forehead–nose –image
receptor

2. X-ray tubehead B

central ray horizontal (0°)

centred through the occiput
Fig 8: Patient position 18
 2.1 Posteroanterior skull (3/3)

Fig 9: PA radiograph with the major anatomical features drawn in

19
.
 2.2 True lateral skull (1/3)
Projection shows : skull vault and facial skeleton from the lateral aspect.

Main indications

• Fractures of the cranium and the cranial base

• Middle third facial fractures( downward and backward displacement maxillae)

• Investigation of the frontal, sphenoidal maxillary sinuses

• Conditions affecting the skull vault, (Paget’s disease of bone

• Conditions affecting the sella turcica (Tumour of the pituitary gland ,

acromegaly) 20
 2.2 True lateral skull (2/3)

Technique and positioning

1. The patient position A

• head turned through 90°

• face touches the image receptor.

2. The X-ray tubehead position

B
• centred through the external
auditory meatus
Fig 10: patient position 21
2.2 True lateral skull (3/3)

Fig 11: True lateral skull radiography of skull 22

 2.3 Modification of lateral position (1/2)
Incidence de Schuller

• Projection shows the TMJ

Main Indication

• Pathology of the TMJ

Techniques
Fig 12 A: Position of the Patient
• Position - head turned through 90°
- face touches the image receptor.
- Head incline 10 to the horizontal plan 23
 2.3 Modification of lateral position (2/2)

B C D
Fig 12 B: Patient position Fig: 12 C- position of condyle mouth open, 12 D- mouth close

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 2.4 Submentovertex (SMV) (1/3)
Axial view (Incidence de Hirtz)

projection shows : skull base, sphenoidal sinuses, facial skeleton

from below.

Main indications

• Investigation of the sphenoidal sinus

• Assessment of mandible (thickness) before osteotomy

• Fracture of the zygomatic arches

• Investigating the skull base.

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 2.4 Submentovertex (SMV) (2/3)
Technique and positioning

1. The patient is positioned

• facing away from the image receptor.

• vertex of the skull touches the image

receptor.

2. The X-ray tubehead

• aimed upwards from below the chin Fig 13 : Position of the Patient

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2.4 Submentovertex (SMV) (3/3)

Fig 14: Submentovertex radiography 27

 2.5 Oblique lateral radiographs (1/7)
(incidence de maxillaire defile)

MAIN INDICATIONS

• Assessment -presence and/or position of unerupted teeth

• Fractures of the mandible

• Evaluation of lesions or conditions affecting jaws

• Alternative to intraoral views - severe gagging or trimus

• specific views salivary glands or temporomandibular joints

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 2.5 Oblique lateral radiographs (2/7)

BASIC TECHNIQUE PRINCIPLES

• The cassette (image receptor)

held by the patient against the side of

the face overlying the area of the jaws
under investigation.

• patient’s head

rotated to side of interest and chin raised Fig 15: Position of Patient
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 2.5 Oblique lateral radiographs (3/7)

• X-ray tube head – 2 position

Behind the ramus aiming through

the radiographic keyhole (A).

Beneath the lower border of the

mandible (B).

A B
Fig 16: Position of x-ray Tube 30
 2.5 Oblique lateral radiographs(4/7)

Important points to note

• The area under investigation determines the position of the

cassette and the X-ray tubehead.

• An X-ray request for an oblique lateral must specify the exact

region of the jaws required.

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 2.5 Oblique lateral radiographs(5/7)

Fig 17: A Cassette and X-ray tubehead positions for the right mandibular and maxillary molars on an adult.
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 2.5 Oblique lateral radiographs(5/7)

Fig 18: A Cassette and X-ray tubehead positions for the right mandibular and maxillary canines.

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 2.5 Oblique lateral radiographs(6/7)

Fig 19: A Cassette and X-ray tubehead position for the right mandibular molars.

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2.5 Oblique lateral radiographs (7/7)

Fig 20: Position of child - Bimolar technique

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 2.6 Standard occipitomental (0° OM) (1/3)

This projection shows : Main indication

• facial skeleton • middle third facial fractures

• maxillary antra • Coronoid process fractures

• NB No superimposition dense • Investigation of the sinus

bones of the base of the skull. ( maxillary frontal and
ethmoidal)
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 2.6 Standard occipitomental (0° OM ) (2/3)
Technique and positioning

1. The patient positioned

• facing the image receptor

• Nose–chin position 45° to the A

image receptor,

2. The X-ray tubehead positioned

• central ray horizontal (0°) B

centred through the occiput

Fig 21 :Position of the patient
37
 2.6 Standard occipitomental (0° OM ) (3/3)

Fig 22: Standard occipitomental radiograph with the major anatomical features drawn . 38
2.7 Modified SMV- Semi-axial
( incidence de Blondeau)

Fig 23: Patient position and SMV -view 39

 2.8 Posteroanterior of the jaws(1/4)
(PA jaws/PA mandible)

• This projection shows the posterior parts of the mandible.

Main indications

• mandibular fracture ( Posterior third of the body, Angles, Rami,

low condylar necks)

• Lesions such as cysts or tumours in the posterior mandible

• Mandibular hypoplasia or hyperplasia

40
 2.8 Posteroanterior of the jaws(2/4)
Technique and positioning
A
1. The patient position to the image
receptor

• forehead–nose position.

2. The X-ray tubehead B

• central ray is centred through the

cervical (level of the rami of the
mandible)
Fig 24: position of the patient41
2.8 Posteroanterior of the jaws (3/4)

Fig 25: The PA jaws radiograph with the major anatomical features drawn in. 42
2.8 Posteroanterior of the jaws(4/4)

Fig 26: The PA jaws radiograph-mouth open 43

 2.9 Reverse Towne(1/3)
PA projection shows condylar heads and necks.

Main indications

• Condylar neck fracture

• Condylar hypoplasia or hyperplasia.

• TMJ disorders

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 2.9 Reverse Towne(2/3)
Technique and positioning

1. The patient - PA position,

A
• forehead–nose position, mouth is open..

2. The X-ray tubehead

• upwards from below the occiput,

• central ray at 30° to the horizontal, B

centred through the condyles 45

Fig 27: position of patient
2.9 Reverse Towne (3/3)

46
Fig 28: Reverse Towne view
 2.10 Rotated posteroanterior(1/3)
(rotated PA)

This projection shows the tissues of one side of the face

Main indication

• Investigate parotid gland

• Ramus of the mandible.

47
 2.10 Rotated posteroanterior(2/3)
(rotated PA)
Technique and positioning

1. The patient is positioned facing the image

• nose touching the image recepto. A

• head - rotated 10° to the side of interest.

2. The X-ray tubehead

• central ray horizontal (0°), aimed down the B

side of the face Fig 29: Position of patient 48

2.10 Rotated posteroanterior (3/3)
(rotated PA)

Fig 30 : rotated PA 49
 Conclusion

• Conventional radiography still plays an important role in the

diagnosis of pathologies in the maxillofacial region

• They exist several projection techniques to show the different

regions of the maxillofacial region/skull

• Knowledge of anatomy is important to rightly interpret the

different x-ray film
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 Bibliography

1. Eric Whaites,Nicholas Drage – Essential of dental

radiography and radiology Churchill Livingstone (2013)

2. Friedrich A Pasler - Atlas Medecine Dentaire Radiologie

3. Koenig -Diagnostic Imaging Oral and Maxillofacial 2 nd edition

4. Indications de la radiographie du crane et/ou du Massif facial

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