EXTRA ORAL RADIOLOGY

Class taken by: Dr Vineetha Manu

The main clinical indications requiring radiographs of the skull and maxillofacial skeleton include: When intraoral radiographs are unobtainable as during trismus To examine the extent of large lesions When jaws or other facial bones have to be examined for evidence of lesions & other pathologies To evaluate skeletal growth & development To evaluate the status of impacted teeth To evaluate trauma To evaluate TMJ, antrum, skull base & vault EXTRA- ORAL RADIOLOGY X-ray source and the image receptor both are placed outside the mouth Requirements Cassettes Intensifying screen Grids in certain cases Films Specialized equipment Differences INTRAORAL RADIOGRAPHY EXTRA- ORAL RADIOGRAPHY

Film placed inside the mouth Smaller film size Covers 2 or 3 teeth and surrounding periapical areas Cassettes not required Intensifying screens and grids not used Less radiation exposure Requires less technical expertise

Film placed outside the mouth Large size films Broader coverage of area

Cassettes mandatory Intensifying screens and grids used More radiation exposure Comparatively Difficult procedure

Common extra-oral radiographs Panoramic radiographs Lateral oblique views Paranasal sinus view

Submentovertex view PA skull and mandible Lateral cephalogram TMJ views

What you should know? WHY these projections are taken? HOW these projections are taken? WHAT the resultant radiograph should look like? PANORAMIC RADIOGRAPH Derived from the word panorama- an unobstructed or complete view of a region in every direction Technique for producing a single tomographic image of the facial structures that includes Both the maxillary and mandibular dental arches and Their supporting structures

Indications of panoramic radiography 1. Screening radiograph for gross teeth / bone status 2. As part of an assessment of periodontal bone support 3. To assessment the location of third molars 4. Condylar evaluation 5. To assess large bony pathologies 6. Fractures of all parts of the mandible except the anterior region 7. Antral disease particularly to the floor, posterior and medial walls of the antra 8. Estimation of dental age Principle Reciprocal movement of an x-ray source and an image receptor around a central point or plane, called the image layer / focal trough in which the object of interest is located 3D curved zone: image layer or focal trough is a three-dImensional curve zone (or focal trough) in which the structures lying within the layer are reasonably well defined on final panoramic image. The structures seen on a panoramic image are primarily those located within the image layer. LATERAL OBLIQUE MANDIBLE Extraoral views of the jaws that can be taken using a dental X-ray set . Before the development of dental panoramic equipment they were the routine extra-oral radiographs used.

Ramus projection and body projection

INDICATIONS Assessment of the presence and/or position of unerupted teeth Detection of fractures of the mandible Evaluation of lesions or conditions affecting the jaws As an alternative when intraoral views are unobtainable As specific views of the salivary glands or TMJ PARANASAL SINUS VIEW (WATERS VIEW)

Occipito-mental projection PA view modification Centered on maxillary sinuses INDICATIONS PNS VIEW Maxillary sinus evaluation Detecting the following middle third facial fracture Le Fort I, II, III, naso-ethmoidal complex Coronoid process Fracture Sphenoid sinus can be visualized if mouth is opened Posterio-Anterior views PA Skull PA mandible PA CEPHALOGRAM

Shows the posterior part of the mandible: body & ramus Symphysis not seen well Not suitable for showing the facial skeleton because of superimposition of the base of the skull & the nasal bones INDICATIONS Fractures of the mandible involving the following sites: ( Posterior third of the body,Angle, Rami) Low condylar necks Lesions such as cysts or tumours in the posterior third of the body or rami to note any medio-lateral expansion Mandibular hypoplasia or hyperplasia Maxillofacial deformities Technique and positioning Exactly the same position as for the PA skull, i.e. the head tipped forward, the radiographic baseline horizontal & perpendicular to the film in the forehead-nose position RADIOGRAPHY OF BASE OF SKULL SUBMENTOVERTEX VIEW: This projection shows the base of the skull, sphenoidal sinuses and facial skeleton from below

INDICATIONS Investigation of the sphenoidal sinus Assessment of the thickness (medio-lateral) of the posterior part of the mandible before o osteotomies Destructive/ expansile lesions affecting the palate, pterygoid region or base of the skull Fractures of the zygomatic arches; to show these thin bones the SMV is taken with reducedexposure factors to almost one third of normal exposure(Jug handle view)

Technique and positioning:The patient is positioned facing away from the film. The head is tipped backwards as far as possible, so that the vertex of the skull touches the film. IMPORTANT: this position is contraindicated in patients with neck injuries, especially fracture of the odontoid peg REVERSE TOWNES VIEW This projection shows the condylar heads and necks The original Towne's view (an AP projection) was designed to show the occipital region, but also showed the condyles.However, since all skull views used in dentistry are taken conventionally in the PA direction, the reverse Towne's (a PA projection) is used

INDICATIONS High fractures of the condylar necks Intracapsular fractures of the TMJ Evaluation of the articular surfaces of the condylar head Condylar hypoplasia or hyperplasia LATERAL CEPHALOGRAM

ALWAYS taken in standardized position. Consistent and accurate positioning of patients head in relation to a fixed position of tube head. So ideal for follow up studies Wedge filter on the anterior aspect of beam, so soft tissue profile also can be studied Centered to external auditory meatus

SPECIAL TMJ VIEWS: Transcranial view Transpharyngeal view Transorbital view TRANSCRANIAL VIEW

Provides a sagittal view of the lateral aspects of the condyle & the temporal component Post auricular or LINDBLOM technique is the most common Gross osseous changes on lateral aspect of the joint only, displaced condylar fractures & range of motion ( open mouth view) Technique and positioning The beam is directed downward from the opposite side through the cranium & above the petrous ridge of the temporal bone at 25 centered through the joint Beam is angled 20 anteriorly TRANSPHARYNGEAL / INFRACRANIAL/ McQUEEN/ PARMA VIEW Provides sagital view of the medial pole of the condyle Limited information, as temporal component not imaged well Erosive changes of the condyle rather than subtle changes Technique and positioning Beam directed superiorly at -5 through the sigmoid notch of the opposite side & 7-8 from the anterior Mouth opened maximally to avoid superimposition of the condyle on the temporal component TRANSORBITAL/ ZIMMER VIEW Provides an anterior view of the TMJ perpendicular to transcranial & transpharyngeal views Entire mediolateral dimensions of the articular eminence, condylar head & neck visible: condylar neck fractures, gross degenerative changes

Technique and positioning Canthomeatal line is adjusted horizontal Beam is directed downward 10 from front of the patient, 30 through ipsilateral orbit & centered over the TMJ of interest

RADIOGRAPHS USEFUL FOR CONDYLAR EVALUATION : Panoramic radiograph Lateral oblique ramus PA mandible Reverse towne SMV

Transcranial Transorbital Transpharyngeal

Mc GRIGOR & CAMPBELL LINES They described a search pattern of four lines when examining the PNS projection Fifth line is known as Trapnells line These lines allow the examination of all those parts of the face where fractures are most likely to be found LINE 1: Across frontozygomatic sutures, superior margins of orbit, frontal sinuses LINE 2: along zygomatic arches, zygomatic body, inferior orbital margin & nasal bones LINE 3: crosses the condyles, coronoid process & maxillary sinuses LINE 4: Crosses the ramus & occlusal plane LINE 5: Inferior border of mandible from angle to angle ADJUNCT LINES OF DOLAN & JACOBY ORBITAL LINE: extends along the inner margins of the lateral, inferior & medial walls of the orbit, passing over the nasal arch ZYGOMATIC LINE: superior margin of the arch & body of zygoma, passing along the frontal process of zygoma to the ZF suture MAXILLARY LINE: inerior margin of the zygomatic arch, inferior margin of the body & buttress of zygoma & the lateral wall of maxillary sinus PANORAMIC INNOMINATE LINE Thin, vertical, radiopaque line in the posterior third of the sinus, composed of panoramic juxt apositioning of two separate bones Lower half: thin cortical outline of the posterior surface of the zygomatic process of maxilla, upper half: posterior surface of frontal process of zygoma