EXTRA ORAL RADIOGRAPHY

• Extra oral radiographic examinations include all views made of the orofacial region with the
films positioned extra orally. They allow the Dentist to view large areas of the jaws and skull on a
single radiograph not covered by intraoral films

PURPOSE AND USE OF EXTRAORAL RADIOGRAPHS:

• Examine large areas of the jaws and Skull.

• Study growth and development of bone and teeth.

• Detect fractures and evaluate trauma

• Detect pathological lesions and Diseases of the jaws.

• Detect and evaluate impacted teeth.

• Evaluate TMJ Disorders.

• Used in the patients who has swelling or discomfort and is unable to tolerate the placement of
intra oral films.
Extraoral radiographs can be used alone or in conjunction with intra oral radiographs.

EQUIPMENT

 X-Ray Unit

 Film

 Intensifying Screens

 Cassette

 Grid

1. X-RAY UNIT
Extra oral skull projections can be made with

 Conventional dental X-ray machines

 Advanced types of Panoramic X-ray machines

 Larger X-ray units designed for extra oral radiography

2. FILM
Currently, there are two groups of X-ray films for dental purposes:
1. Non-screen - Those with emulsions more sensitive to direct exposure of X - rays. These are primarily
used as intraoral films and provide excellent image quality.
2. Screen - Those with emulsions more sensitive to blue [standard] or green [rare earth] light (Emitted
when X-rays strike the intensifying screens). The X-ray photons are converted to visible light photons.
Screen film is used for extraoral views, such as panoramic, cephalometric and TMJ imaging.
Unfortunately, it does not produce the image detail of non-screen films. Screen films are always used
IN COMBINATION with intensifying screens.

• With screen-film, it is mainly the light photons from the intensifying screens that produces the
image on the film and not the x-ray photons. Intensifying screens permit a good radiograph to be
produced with the patient receiving a much lower dose of radiation.

Size of the Film

• Lateral Oblique view of the mandible – 5 x 7 inches

• Panoramic projections 5 x 12 or 6 x 12inches

• Skull projections- 20 x 25cm or 8 x 10 inches

• An occlusal film{size 4} may be used for some extra oral radiograph

[e.g; lateral jaw or trans cranial projection]

• An occlusal film is a non-screen film & does not require the use of screens for exposure

3. INTENSIFYING SCREENS.
• An intensifying screen is a plastic sheet coated with fluorescent material called phosphors.
Phosphors are materials which convert photon energy to light.
The luminescent effect is used radiographically in two ways:
1. To obtain an image on a fluorescent screen as in fluoroscopy, and
2. To increase the photographic response of the silver halide emulsion.

• In this case the fluorescent material is placed in the emulsion layer on the intensifying screen, in
direct contact with the film during exposure. Since X-ray films are coated with emulsion on both sides,
intensifying screens are employed in pairs.

• Each emulsion surface is placed in close contact with the effective surface of one intensifying
screen, to avoid loss of image sharpness.

Speeds of Intensifying Screens.

1. Fast screens - thick layer, and relatively large crystals used, maximum speed is attained but with some
 sacrifice in definition.
2. Slow screens or high definition screens - a thin layer and relatively small crystals are used; detail is the
best, but speed is slow necessitating a higher dose of ionizing radiation.
3. Medium screens - medium thick layer of medium sized crystals in order to provide comprise between
speed and definition.

There are three types of intensifying screens:

a) Standard - slow screens
b) Rare earth - fast screens
c) Combination

• Standard screens use calcium tungstate phosphors, while rare earth screens use gadolinium
or lanthanum phosphors. The commercial name for rare earth screens is Lanex.

• Rare earth phosphors are more efficient at converting X-rays to visible light thus reducing the
radiation further to the patient.

• The manufacturers name and the type of screen are printed on the one side of the screen and this
information appears on the radiograph.

• The intensifying screen is placed in a cassette in close contact with a film. The visible light from
its fluorescent image will add to the latent image on the film.

• Its function is to reinforce the action of X-rays by subjecting the emulsion to the effect of light as
well as ionizing radiation.

• The benefit is the reduction in dose of ionizing radiation to the patient.

Characteristics of Intensifying Screens

1) An intensifying screen consists of a base of polyester or cellulose triacetate similar to radiographic film
2) This base must be radioparent
3) and chemically inert.
4) It must combine characteristics of toughness and flexibility
5) should neither curl
6) not discolor with age.
7) The base is first coated with a reflective layer of titanium dioxide to bounce light back onto the film.
Divergence of the light rays causes unsharpness of the image.
8) uniform homogeneous phosphor layer- standard or rare earth.
9) covered with a thin transparent supercoat consisting of gelatin. The purpose of the latter is protective,
and is very thin and care is always required in handling intensifying screens to avoid any kind of
abrasion
10) The flexibility of the material is important to allow the screen to bend without cracking - an
intensifying screen of this type is used in the panoramic cassette.

• Each crystal on the screen emits bluish light for regular screens (or green light for rare-
earthscreens)

• Brightness is related directly to the intensity of the X-rays in that minute portion of the image.
Thus, over the entire surface of the screen, differences in X-ray intensities are transformed into
differences of bluish light (green light) brightness to which the film is highly sensitive.

• The entire image is thus intensified for recording by the film. The larger the crystals and the
thicker the fluorescent layer on the screen, the more light is produced and the greater the
intensification.

• However, the light spreads more widely and the sharpness of detail of the image is decreased
accordingly. Manufactures have attempted to improve image quality without sacrifice to film speed by
using phosphor crystals of different shapes. An example of this is the T-Mat film that we use for
panoramic and extraoral radiographs.

• The film-screen combination must be matched so that the emission characteristics of the screen
match the spectral sensitivity of the film.

• It is also important to note that when double-loading cassettes, one must use a faster film (e.g.: T-
Mat H) or increase the kVp as only one side of each film will be in contact with the intensifying
screens.

4. CASSETTES

A flat, light-tight container in which x-ray films are placed for exposure to ionizing radiation and
usually backed by lead to eliminate the effects of back scatter radiation.

Cassettes are used in association with intensifying screens and screen films. They have related functions:
1. to contain a film
2. to exclude light,
3. to maintain the film in close, uniform contact with both screens during the exposure
4. to protect the intensifying screens from physical damage.
Properties of a cassette:
a) weight - It should be light for easy manipulation
b) robust structure - cassettes in daily use are subject to considerable stress and wear. Screens may fail to
maintain contact with the film or leakage of light at the edges can occur. Cassettes deserve and should
have stringent care in handling.
c) i. Non flexible - so as not to allow the film to bend.
ii. Flexible cassettes - for panoramic machines.

• Flexible cassettes are necessary for the specialized equipment associated with panoramic
radiography. They are mounted within a simple envelope of plastic material, folded at one end and
fastened with press buttons or velcro of conventional design. The cassette is attached to a drum and is
rigid for the duration of the exposure.

d) Size - Slightly larger than the x-ray beam and area to be radiographed.
e) Ease of operation.

5. GRID
• A Grid is a device used to reduce the amount of scatter radiation that reaches the extra oral film
during exposure. Scatter rays cause film fog. The grid is used to decrease film fog & increase the
contrast of the image.

• A Grid is composed of a series of thin lead strips embedded in a plastic that permit the passage of
x-ray beam. IT is placed between the patient head & the film.

• Some radiation interact with the patient tissue, scatter radiation is produced; this scatter rays then
directed at the grid & the film at an angle.

• As result, scatter rays are absorbed by the lead strip does not reach the surface of the film to cause
film fog.

STEP BY STEP PROCEDURE

For exposure of extra oral film include-

* Equipment preparation.

* Patient preparation.

* Patient positioning.

EQUIPMENT PREPARATION
 • Load the extra oral cassette in the dark room under the safe light conditions.

• Place the extra oral film between two intensifying screens & securely close the cassette.

• Load the cassette into the cassette carrier.

PATIENT PREPARATION
• Explain the patient the radiographic procedure about to be performed.

• Place a lead apron without a thyroid collar over the patient & secure it. a double –sided lead
apron is preferred.

• The lead apron must be placed low around the back of the neck so that it does not block the x-ray
beam.

• A thyroid collar is not preferred for extra oral radiography because it blocks part of the beam &
obscures diagnostic information.

• Remove all the objects from head & neck region, that may interfere with the film exposure like
eyeglasses, earrings, dentures, hearing aids.

VARIOUS PROJECTIONS OF EXTRAORAL RADIOGRAPHY

 Panaromic Radiography

 Posteroanterior Projection of the Skull & Mandible

 Lateral cephalometric projection

 Water’s projection

 Submentovertex projection

 Bregma – Mentum Projection

 Reverse-Towne’s Projection

 Towne’s Projection
  Lateral oblique Radiography

 Temporomandibular Joint radiography

SKULL PROJECTIONS

STANDARD OCCIPITOMENTAL (0° OM)

• This projection shows the facial skeleton and maxillary antra, and avoids superimposition of the
dense bones of the base of the skull.

Indications
• Investigation of the maxillary antra

• Detecting the following middle third facial fractures: – Le Fort I

– Le Fort II
– Le Fort III

– Zygomatic complex

– Naso-ethmoidal complex

– Orbital blow-out

• Coronoid process fractures

• Investigation of the frontal and ethmoidal sinuses.

• Investigation of the sphenoidal sinus (projection needs to be taken with the patient’s mouth open).

30° OCCIPITOMENTAL (30° OM)

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

Indications
● Detecting the following middle third facial fractures:
– Le Fort I
 – Le Fort II
– Le Fort III
● Coronoid process fractures.

POSTEROANTERIOR OF THE SKULL (PA SKULL)

• This projection shows the skull vault, primarily the frontal bones and the jaws

Indications
● Fractures of the skull vault
● Investigation of the frontal sinuses
● Conditions affecting the cranium, particularly:
– Paget’s disease of bone
– multiple myeloma
– hyperparathyroidism
● Intracranial calcification.

USES

 To examine the skull for disease, trauma or developmental abnormalities

 To detect progressive changes in the mediolateral dimensions of the skull

 Good visualization of facial structures including frontal & ethmoid sinuses, nasal fossae
& orbits.

POSTEROANTERIOR MANDIBLE PROJECTION

• This projection shows the posterior parts of the mandible.

Indications:
• Fractures of the mandible involving the following sites:
– Posterior third of the body
– Angles
– Rami
– Low condylar necks
 • Lesions such as cysts or tumours in the posterior third of the body or rami to note any
mediolateral expansion

• Mandibular hypoplasia or hyperplasia

• Maxillofacial deformities.

REVERSE – TOWNE’S PROJECTION

• This projection shows the condylar heads and necks.

Indications:
• High fractures of the condylar necks

• Intracapsular fractures of the TMJ

• Investigation of the quality of the articular surfaces of the condylar heads in TMJ disorders

• Condylar hypoplasia or hyperplasia.

TOWNE’S PROJECTION (300 Fronto-occipital)

Position of the Head:
Film back to the head
Projection of the CR:
Directed 300 to floor & 5cm above the nasion.
Uses:
1. Good view for the neck of the condyles
2. Antero posterior projection of the head of the condyles, for comparison, & movement of the
condyles (Townes with the mouth open)

ROTATED POSTEROANTERIOR (ROTATED PA)

This projection shows the tissues of one side of the face and is used to investigate the parotid gland and
the ramus of the mandible.

Main indications
 • Stones/calculi in the parotid glands

• Lesions such as cysts or tumours in the ramus to note any medio-lateral expansion

• Submasseteric infection — to note new bone formation.

TRUE LATERAL SKULL

• This projection shows the skull vault and facial skeleton from the lateral aspect.

Main indications
• Fractures of the cranium and the cranial base

• Middle third facial fractures, to show possible downward and backward displacement of the
maxillae

• Investigation of the frontal, sphenoidal and maxillary sinuses.

• Conditions affecting the skull vault, particularly:

– Paget’s diseaseof bone
– multiple myeloma
– hyperparathyroidism

• Conditions affecting the sella turcica, such as:

– tumour of the pituitary gland in acromegaly.

CEPHALOMETRIC RADIOGRAPHY
• Cephalometric radiography is a standardized and reproducible form of skull radiography used
extensively in orthodontics to assess the relationships of the teeth to the jaws and the jaws to the rest of
the facial skeleton.
EQUIPMENT

• Several different types of equipment are available for cephalometric radiography, either as
separate units, or as additional attachments to panoramic units.

MAIN INDICATIONS
Orthodontics

• Initial diagnosis — confirmation of the underlying skeletal and/or soft tissue abnormalities
 • Treatment planning

• Monitoring treatment progress, e.g. to assess anchorage requirements and incisor inclination

• Appraisal of treatment results, e.g. 1 or 2 months before the completion of active treatment to
ensure that treatment targets have been met and to allow planning of retention.
Orthognathic surgery

• Preoperative evaluation of skeletal and soft tissue patterns

• To assist in treatment planning

• Postoperative appraisal of the results of surgery and long-term follow-up studies.

USES:

 Orthodontists use it to assess facial growth

 To identify the position of certain anthropometric land marks

 Used in oral surgery & prosthetics to establish pre-treatment & post treatment records

 To survey the skull & facial bones for evidence of trauma, disease or developmental
abnormality

 Reveals the nasopharyngeal soft tissues, Para-nasal sinuses & hard palate

MAIN RADIOGRAPHIC PROJECTIONS

• True cephalometric lateral skull

• Cephalometric posteroanterior of the jaws (PA jaws).

LATERAL CEPHALOMETRIC PROJECTION

(LATERAL SKULL PROJECTION)
Film Placement:
The film positioned parallel with the sagittal plane of the skull
Head Position:
Head is positioned with the left side of the face near the cassette.
Projection of the CR:
CR is directed towards the external auditory meatus
Exposure Parameters:
Film-source distance – 60 inches, KVp-70, mAs – 15 to 25
CEPHALOMETRIC POSTEROANTERIOR OF THE JAWS (PA JAWS)

• This projection is identical to the PA view of the jaws, except that it is standardized and
reproducible. This makes it suitable for the assessment of facial asymmetries and for preoperative and
postoperative comparisons in orthognathic surgery involving the mandible.

SUBMENTOVERTEX (SMV) (Base or Full axial Projection or Infero Superior zygomatic arch
projection)
Main indications

• Destructive/expansive lesions affecting the palate, pterygoid region or base of skull

• Investigation of the sphenoidal sinus

• Assessment of the thickness (mediolateral) of the posterior part of the mandible before osteotomy

• Fracture of the zygomatic arches — to show these thin bones the SMV is taken with reduced
exposure factors.

PROJECTION OF THE Central Ray:

CR is directed below the madible upward & toward the vertex of the skull, midway between the two
zygomatic arches.

EXPOSURE PARAMETERS:

Tube object distance is 18 inches, 65 KVp, 100mAs

WATER’S PROJECTION
(Occipitomental Projection or PNS view of the skull or PA maxillary sinus projection)

PROJECTION OF THE CR:

Passes at the level of the max. sinus.

EXPOSURE PARAMETERS:
Film source distance is 24 inches,
KVp-65, mA-10, exposure time is 1½ sec.

USES

• Useful for evaluating the maxillary sinuses

• It demonstrates the frontal, ethmoidal sinuses, the orbit, zygomatico frontal suture & the
nasal cavity

• Position of the coronoid process between the maxilla & zygomatic arch

• The detection of fluid level in the maxillary sinuses.

BREGMA-MENTUM PROJECTION
Film Placement:
Film is placed horizontally on a metal table
Head Position:
The Cassette is positioned under the chin & extended as far as possible.
Projection of the Central Ray:
Enters at the bregma and exits at the mentum
Uses:
1. Useful in the examination of medial or lateral deviations of any part of the mandible
2. The anterior, Posterior, medial & lateral walls of the maxillary sinus, nasal cavity & orbits are
clearly portrayed.
3. Shows the mandibular condyle & zygomaticarches

LATERAL OBLIQUE VIEW OF THE MANDIBLE

A. MANDIBULAR BODY PROJECTION

Demonstrates the premolar-molar region & inferior border of the mandible.

FILM PLACEMENT: Placed against the patients cheek

HEAD POSITION:
Head is tilted toward the side being examined & the mandible is protruded.

PROJECTION OF THE CR: Directed toward the first molar region from a
point 2cm below the angle on the tube side.

EXPOSURE PARAMETERS: 65KVp, 10mA, exposure time-1/4 sec.

Object-source distance-8” or more (12 inches)

B. MANDIBULAR RAMUS PROJECTION

View of the ramus from the angle of the mandible to the condyle.
Useful for third molar examinations

FILM PLACEMENT:
Cassette is placed over the ramus & posteriorly to include the condyle.

HEAD POSITION:
Head is tilted toward the side of the mandible being examined, mandible should be protruded.

PROJECTION OF THE CR:

Directed towards the centre of the ramus, 2cm below the inferior border of the first molar region on the
tube side.

EXPOSURE PARAMETERS:
Same

USES

 Patient cannot open the mouth

 In very young children, geriatric patients & with the extreme gag reflex

 Shows the boundaries of large lesions & in evaluation of bone

TEMPORO MANDIBULAR JOINT TOMOGRAPHY
• This area is difficult to examine radiographically because of the adjacent bony structures.

• Radiographically cannot be used to examine articular disc & other soft tissue area of TMJ.

• Special imaging technique e.g., Arthography & MRI must be used.

• The following techniques can be seen in TMJ radiography;

TRANSCRANIAL PROJEC TION
TRANS ORBITAL PROJECTION
TRANS PHARYNGEAL PROJECTION TMJ
TOMOGRAPHY.

TRANS ORBITAL PROJECTION

PURPOSE:

• Used in the visualization of the joint with relatively less superimposition.

• It is also called ZIMMER or TRANSMAXILLARY PROJECTION.

• This view demonstrates the entire mediolateral dimension of the articular eminence, condylar
head, and condylar neck.

FILM PLACEMENT:

• The cassette is placed behind the patient head.

HEAD POSITION:
In the sitting position, the head of the patient is tipped about 10 degrees in such a way that the cantha-
meatal line is horizontal.

• The mid sagittal plane is kept at 30 degrees to the central x-ray beam by moving the head to the
left for left side projection & to the right for the right side projection.
BEAM ALINGMENT:
The central x-ray beam is directed thro frough the ipsilateral orbit & through the required TMJ exiting
from the skull behind the mastoid process.

• During exposure the patient is asked to open the mouth as wide as possible.

USES
 • Useful for visualizing condylar neck fractures.

• The morphology of the convex surface of the condylar head can be evaluated

• The usefulness of this projection is limited by the ability of the condyle to move to the summit of
the articular eminence.

• If condylar motion is limited, only the condylar neck is visible because areas of the joint
articulating surfaces are obscured by superimposition of the temporal component on the condylar head.

TRANS CRANIAL [LINDBOLM] TECHNIQUE

PURPOSE:

• To evaluate the superior surface of the condyle & the articular eminence.

• Also used to evaluate the movement of the condyle when the mouth is opened & to compare the
joint spaces.
FILM PLACEMENT:

• The cassette is placed flat against the patient’s ear & is centered over the TMJ.

HEAD POSITION:

• The mid capital plane must be positioned perpendicular to the floor & parallel with the cassette.
BEAM ALIGNMENT:

• The central ray is directed toward a point 2inches above & 0.5 inch behind the opening of the ear
canal.

• The beam is directed downward (25º) and 20º anterior angle and is centered on the TMJ that is
being imaged.

TRANSPHARNGEAL PROJECTION
• Also called INFRACRANIAL, PARMA or MCQUEEN PROJECTION.

• PURPOSE: This projection demonstrates the condylar process from mid mandibular ramus to
the condyle.

• This technique helps in the diagnosis of fractures of the condyles & the condylar neck & in
detecting alternation in the condylar morphology.

• FILM PLACEMENT- The cassette is held over the ear in such a way that the TMJ of interest is
in the center of the cassette.

• The cassette is held parallel to the mid sagittal plane.

 • Beam alignment-The x-ray tube is kept on the side of the skull opposite to the TMJ imaged.

• It is angled in such a way that the central beam is directed cranially 5 to10 degrees & posteriorly
approximately 10degrees before the exposure ,the patient is asked to open the mouth wide so that the
central x-ray beam enters the sigmoid notch, below the skull base, oropharynx & through the TMJ of
the film side in a oblique direction to the long axis of the condyle.

CONCLUSION :

• Extraoral oral radiography is a valuable diagnostic tool.

• The different projections that have been described can be used in the detection and evaluation of
various pathological changes fractures growth of the skull and evaluation of dentition, asymmetry,
developmental disturbances.