"The extra oral radiography"

radiography"
Before we start :

The lecture was written without slides so the no. of pictures in the lecture is not exact but approximate.

There're some points not read by the doctor so you should go to slides (when available) and read them.

The good news that the doctor does not get attendance so if you like to be absence
you can do that without losing marks or any other complications.

We started in the last week with the skull radiography and we said that the most
common extraoral or skull radiograph used in dentistry is the panoramic radiograph
and we said why is that? bcz we need to see the dentition as well as the surrounding
structures and we want to see both jaws as sharp as possible , bcz as you know in the
extraoral radiograph , the degree of sharpness decreased compared to the intraoral
radiographs, but we always like to give a brief idea about the other types of radiographs
which might be used in dentistry in the skull techniques , and as we said when we say
skull or extraoral radiographs means that the film is placed outside the patient mouth
and the area covered or seen on the film larger than those in the intraoral films
otherwise the technique of choice is always the intraoral.

And when we say extraoral radiographs , the most common is the panoramic
radiograph also we have the lateral jaw , cephalometric , skull and TMJ views.

Indications for skull radiographs :

When we go to skull radiograph ?

as we said in the panorama , almost the indications is similar in all types of extraoral
radiographs , except certain areas appear on the extraoral films sharper than others , so
according to the indication we go for one of the six techniques which we will talk about
after awhile .

So the indications are:

• To examine areas not fully covered by intraoral films : and this information become
a common sense for us ,bcz when the film exposed directly by the x-ray photon , the
degree of sharpness as well as the contrast will be better than those exposed

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 indirectly and always every skull radiograph exposed indirectly .(I don’t know what is the
relation between the point and the explanation of it , but I think that the doctor wanted to say that the extraoral films
are larger than those intraoral ones that’s why we use them to examine areas not fully covered by intraoral films).

• To visualize skull and facial structures : the parts which are important for us is
the head and neck , we don’t care about the chest so the views is always
restricted to those areas .

• To evaluate growth in orthodontics: all of you know that the cephalometric

radiograph is mandatory before proceeding in your treatment.

Which type of x-ray machine might be used for skull radiograph?

The intraoral periapical x-ray machine can be used with certain limitations

Also we have the larger x-ray unit which usually designed for extraoral radiography
and we call it the craniotome which has the same composition as other x-ray machines ,
so we have glass envelope inside the tube head , we have filament ,we have the target
and the only difference is that the Kv used with skull radiograph usually higher than
those in the intraoral , so the difference in potential between the negative and the
positive is more , and more means that the kinetic energy for the emitted electrons is
more , means that the ability of those electrons to reach K shell or nucleus is more ,so
this means that the energy of the produced photon is more , that’s why we prefer to use
a specific x-ray machine rather than intraoral x-ray machines , bcz when the Kv is small
we need to increase the amount of radiation and how we can increase the amount of
radiation ? by increase the ma (milli amper)or s (time) .

• Also we prefer to use those specific x-ray machines bcz its easier to fix the tube
head and the head in a standardized position as we will see later, and we
always have cassette carrier where the film should be placed.

we saw in the panorama that both the image receptor and tube head from the other
side are connected to each other , but in the skull machines its different the tube head
and the image receptor are separated but they move in one direction .

Now in the intraoral we see movement in the horizontal and vertical dimension , and
as doctor ghaida told us that we should respect the vertical as well as the horizontal
angle , bcz increasing or decreasing in the vertical angle causes either elongation or
foreshortening of the image , and movement in the horizontal causes overlapping .

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 And for remembering what is the difference between vertical and horizontal always
English people told us to imagine somebody who is saying yes and this is vertical , and to
imagine someone who is saying no for the horizontal .

So any changes in the horizontal angle left or to the right side causes overlapping ,
what does it mean overlapping ? its means that a structure will overlay over another
structure .

Now in the skull units we don’t have horizontal movements , we only have
movement in the vertical plane all the time , so we don’t have the problem overlapping
in the skull radiographs .

Cephalostat :
The cephalostat is the equipments that we fix with it the head in the ideal position
and does not allow the patient to move in any direction , so that for the image to be
reproducible , and we said why we need our image to be reproducible, bcz we said that
the geometrical as well as the physical factors will affect the size of the legion or the
sharpness of the legion , and as you know the size is a key factor we depend upon in
order to differentiate between certain pathologies .

So if we are talking about ortho we need a cephalostat in order to make assessment

between the preoperative radiograph and the postoperative , usually in ortho we make
pretreatment radiograph and we make post one , to see if we achieve our goal , for ex. If
we want to make movement for upper teeth 2 or 3 mm , we can know if we achieve this
or not if the position is standardized , otherwise we cannot rely on the post operative
radiograph to asses such treatment if the position is not.

This is an example of intraoral x-ray machine slide no.(5) which may be used for skull
radiograph .

Or this is another type slide no.(6) panoramic and cephalometric machine used for
skull radiographs .

Or the craniotome which we were talking about slide no.(7) where we have the tube
head in one side and the cassette carrier in the other side and the patient will be in
between .

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 When we talk about cephalostat this means that we are talking about special devices
that enter in to the ear , and we make stabilization for the head in the horizontal or left
right angle , plus we have for the front side of the head , if someone of you use the
cephalometric machine and saw the cephalostat device which makes supporting for the
head in the two dimensions the horizontal as well as the vertical , so if we want to
radiograph the same patient again , and ear rods enter only in a specific position and the
front part is in a fixed position , so the position of the patient in relation to the image
receptor is constant .

We said that increasing the distance between the image receptor and the object
leads to magnification, and decreasing in this distance causes minimization in the size of
the object, that’s why the constant position of the patient is important.

And as we said before, the pathology healed or not is dependent on the size, if the
image was magnified then even if there was healing it will appear as if there no healing,
and if the size is decreased it will show me that there is healing while it is not, due to the
magnification factor of the x-ray film.

So the cephalostat allows me to fix the relationship between the image receptor and
the object.

Then the physical components : either it is printed on film (Kv,ma ……etc), or it will be
in patient file , when we want the image to be reproducible we ask the technician about
the physical components used for this patient , so in the postoperative radiograph we
depend on the same exposure factors for the image to be reproducible .

These are the ear rods(on ears), and this is the

front part so the midsagittal is respected and the

Frankfort or the horizontal is also respected so I don’t

have any problems in order for the image to be

reproducible.

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 When we say skull radiograph we talk about _as we said in panorama _ cassette inside of
which you will find two screens and film , so it’s the same composition for the cassette
we saw in panorama and any other extraoral films , the only difference is in the sizes.

According to the area to be imaged we select the size, for ex. If I'm talking about the TMJ
(12*12) is enough , but when I'm talking about the whole skull I need more (18*22) so
the selection of the size of the cassette and film depend upon the area to be imaged .

We have an addition thing in the skull radiography machines and only in the
craniotome , not existed in the panorama or in intraoral radiographs , which is something
called grid , now the importance of grid is that it reduces the fog , which comes from
where ?

We said that most of the interactions between the x-ray photon and the human body
is Compton effect (and as you know Compton effect means scattered photons and scattered photons
means that unwanted photon will arrive to the image and I don’t want it to arrive), and you know
that the photon that I want to arrive to the image is the photon which reach both (film
and object) at right angle.

Remember: the ideal image is produced when the long axis of the object and the long
axis of the film are parallel to each other, and the x-ray beam should be directed at right
angle to both.

Now if it is deflected or scattered photon, so there will be changes in the angle, it may
be (30,40,50 ,60, 90……etc) nobody can tell, so if this photon will reach the film it will not
be at right angle , so that unwanted photon or unwanted light will cause what we call fog
and we talked about the fog in the intraoral films and where it come from .

This is the cassette and screens slide no.(11) , two screens one on the top and the
other on the bottom and the film in between and we call this sandwich technique .

This is the antiscattered grid(next page), now what happened is that this x-ray photon

should penetrate through the object to be radiographed (through the skull) then it should

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reach the film, now before reaching the

film we have this antiscattered grid

(named grid in the picture) .

What is the principle of it?

It is an alternative strips (gray red, gray red …) one of them is plastic and the other is
lead , the plastic one allows the x-ray photon to enter through this grid, and the lead
which has high atomic number will do absorption(photoelectric absorption for the photon)
so the deflected photon will make an interaction with the lead so it will not reach the film
and the direct photons which are at right angle will enter through the plastic, and the
atomic number of the plastic is very low and even if there is an interaction the photons
will lose very small energy without deflection so the photons will reach the film at right
angle, and by this we decreased the scattered photon which will reach the film, and by
this we decreased the fog and if its decreased then we will achieve better contrast.

Now did all deflected photons hit the lead strip in the grid?

Definitely no , some of them enter through the plastic so there will be fog , so that’s
why this is another reason why the quality of the skull radiograph lower than the
intraoral , bcz whatever we did the deflected or scattered photon will reach the film .

So the skull radiograph is lower than the intraoral bcz of:

1- The indirect exposure

2- the number of scattered photon that reach to the film without any benefit

Now in the intraoral if we don’t use the long cone paralleling technique

_ as Dr.ghaida told us_ we should respect the patient head position, we should respect that
the occlusal plane is parallel to the floor , and the midsagital

is at right angle.

In the extraoral , it is to somehow similar but

instead of the occlusal plane we either take the

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Frankfort plane or what we call the radiographic base line, now regarding the midsagital
it should be respected with both, bcz as we said in the panorama tilting or twisting in the
midsagittal plane will cause one side to be closer to the image receptor more than the
other side , so there will be a magnified side and the other decreased in size , so the
midsagital should be respected in all radiographic views either intraoral or extraoral,
and the changes only in the horizontal line .

Remember: the Frankfort plane is parallel to the occlosal plane, but usually we want a
line which can be easily visualized, for ex. If I'm talking about occlusal plane and I want to
take lateral radiograph it is hard to it, but if I'm talking about the frankfort plane which is
from the external auditory meatus to the lower border of the orbit* (look to the picture) it will
be easily visualized.

The doctor said that when he give this lecture the level of this lecture is higher than
the level of undergraduate students , but the reason why he give this lecture is
that, suppose for ex. That there is someone existed in a far village and he get a car
accident, and as you know one of main factors for saving life is the doing of procedures
quickly, so if I'm a dentist and working in a clinic and I have a craniotome, at least I should
be able to do the correct views, so that when I make referral for this patient he will not
lose time again for repeating this radiograph.

So doctor give this lecture to know the indication of each view, and how you can do it
easy, but the interpretation of such views is higher than the level of undergraduate
students, even the tracing of outline of the anatomical landmarks is difficult and
complicated, so we need to know the indication and the technique.

Now the name given to any radiograph depend upon the path of the x-ray beam
from where it enter and from where it leave , for ex. Periapical bcz its behind the apical
area , bitewing bcz the patient going to bite on a wing, occlusal plane bcz its against the
occlusal plane, lateral bcz its in the lateral side .

When we say PA it means that the point of entering is from posterior toward the
anterior , now when we see after awhile occipitomental (waters)it means that the point
of entering is from the occipit and the point of exit is from the mental area .

*maybe its different from the one in the prosto which is from the tragus to the ala of the nose (bcz doctor and picture said
its to the lower border of orbit)

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Remember: there is difference between the PA (periapical) and the PA skull and the way
to differentiate between them is that if the radiograph is a PA skull so it’s a must to
mention on the order PA skull (posterior anterior projection).

In the PA skull the beam pass in a posterior to anterior direction through the skull.

PA skull used to examine skull for : (you should know these indications)

Trauma, disease , developmental abnormalities …..etc (existed in the slides but not read by doctor )

The cassette positioned vertically in front of the patient head, and bcz its PA skull it
will enter from posterior toward the anterior

then it will reach to the film so obviously the

film should be in the anterior part , also

the canthomeatal line or the Frankfort plane

parallel to the floor (central ray directed at

something from a source of 36 – 40 inches ….. this is all to remember from slides).

Now this is what is important , this is the nose for head touch _ later on you will see nose
chin touch_ this is the important thing to know how the patient

should be when taking the radiograph,when we say

forehead nose touch it means that the midsagittal is

definitely at right angle to the floor, now regarding

the horizontal the ear rods of the cephalostat will not enter

until the back of the patient is erect (upright) , so this is the grid (in front of the film nearer to
face of the patient ) and next to it is the film so there will be filtration before reaching the
film .

And the Kv depend upon the type of film used , the size of the skull , the sex of the
patient …etc .

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This is an image of a PA skull, and if we look to the arrow

it is very clear that I have fracture (when I see discontinuity

or there is a radiolucent line crossing horizontally this means

that there is a fracture in that area ) .

As you can see in the upper picture the frontal sinuses appear very nice so in this view
I can assess the frontal sinuses very well.

There are many diseases that may have signs on the skull, like paget disease which
shows us cotton roll appearance (this is an easy sign), also the myeloma which shows us
punching out in the skull (radiolucent holes in the skull), so

this is one of the best views to achieve a positive diagnosis to

such diseases.

This is a picture taken with an intraoral x-ray machine

as you see the cone is rounded (6 cm) , so it will show me

limited area in contrast to the skull machines where the

photons reaches the whole skull , but I can use it sometimes

if I don’t have skull machine and I suspect a fracture in the condyler neck and I have
periapical machine so all what I need is cassette and film to take the radiograph and then
assess that area.

One of the students asked about the mandible in the previous picture ?

The Dr : this area (the mandible) was cut bcz the size of the beam is only (6 cm) so
there will be nothing (cone cut) and this happens when the beam not covering an area
and behind this area there is a film ,and this cone cut is not bcz of positioning of the
patient but bcz the cone size is less than it should be , and if I want the condyle (part of
the mandible) to be shown I will move the cone downward but the maxilla will not be
shown.

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 This is a picture of the anatomical land marks on the skull slide no. (21), and the
doctor did not talk about it bcz there will be a separate lectures , one of them for the
landmarks of the maxilla and the other for the landmarks of the mandible .

Lateral cephalometric projection (lateral skull projection) :

Used to survey skull and facial bones, (trauma, disease(present in all indications)) …..etc.

the placement of the film is vertical (but in the picture its horizontal)bcz its

for the lateral side and this is the position

beside, then this view could be for the lateral

view or it could be cephalometric slide no.(24)

(remember both are lateral views but one is cephalo and the other is only lateral)

How we can differentiate between the two ?

In the cephalometric you must use the cephalostat plus you have an anterior wedge
or filter to show the soft tissues, while in the lateral I don’t bother about the soft tissue
so there is no need for filter, and there is no need for the cephalostat if it is just
assessment for fracture or trauma in the right or the left side .

This is the lateral view with filter, how I know that?

bcz I saw the lips and the nose (which are soft tissues), and

you will learn later In ortho the tracing where it

is important for me to see soft tissues .

Also as we said previously about paget`s disease and multiple myeloma we can see if
there is cotton roll appearance or punching out in the lateral view.

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Waters projection(sinus view): (there is another name for it but the doctor can`t remember it)
It is a view used for assessment of the sinuses

in general (not only maxillary sinuses) , and you can

see in the slide no. (29) one of the best views for

the maxillary and ethmoidal sinuses in the

waters projection .

remember : we said that we can assess the frontal sinuses by the PA skull, but also in
this projection (waters projection) we can assess the frontal , maxillary and ethmoidal
sinuses.

This is another picture where we have only chin touch

so the head is extended backward , and the radiographic

base line *is almost parallel to the midsagittal plane or

at right angle to the floor, and this position is to avoid

superimposition of the bone on the sinuses .

Here the maxillary sinuses and the ethmoidal sinuses appear very nice (left)and in the
next picture (middle)we have the frontal sinuses appear very clear so this is the best
view where we can assess any legion within the sinuses (like sinusitis).

This is another view with periapical x-ray machine (above right), you can see a
roundation in this picture, then another picture regarding anatomical landmarks(not
required now).

*as you see the Dr said that this line is parallel to the floor in p7, now he said its parallel to the midsagiFal so I will ask him about that and inform you later.

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Reverse townes projection :
The town`s projection is when the point of entering is from the anterior toward the
posterior, so the reverse town will be with the same position but in the opposite
direction (enter from posterior toward anterior) .

The patient mouth in this position should be open bcz it help us to assess the
condyler head if I have erosion or fracture or whatever.

You have to know that this is one of the views which we not used to go for any more ,
bcz by the invention of MRI and CT scan this radiograph lost its value.

In the townes view the film is in the back and the point of entering is from the
anterior but in the reverse town it’s the same position of the patient`s head in relation to
the film but the point of entering is the opposite, why is that is to have the least
superimposition of the bone so that to show us the condyler head.

And this is the position (1st &2nd left), and the image which will appear for us (3rd from
left)and this is the neck and the head of the condyle (same picture) , then in the next picture
there is a fracture (notice the arrow).

The submentovertix :
The most important thing about it, is that it is the best view to assess zygomatic arch
fracture, but if you are in a far village and a patient came to you following car accident
you should do the required radiograph at least, before referring that patient to the
radiologist or the surgeon.

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 FP

extraoral x-ray
unit

floor

This radiograph (the middle picture) is contraindicated if we have suspicion to neck injury
if you radiograph the patient with this position and you suspect head injury the Dr. can
assure you that the patient will remain on the chair.

Now you suspect neck injury if there is bleeding from the ear and nose, and if you
see that, don’t approach the patient to this view, bcz in this view you extend the neck
backward and this is very dangerous.

As you see in this view (the right picture) you see the submentovertix view, you can see
the zygomatic arch very clear , so this is one of the best views to assess fracture in this
area .
On the syllabus we have two lectures about panorama and we finish with only one , bcz the second
one is slides or radiographs which will be part of your duty in the clinic to see the technical mistakes and
identify them , and also we have two lectures about the skull in the syllabus and we finished by one , so
with the other lecture we may take brief idea about MRI and CT scan and maybe not , and this depends
on the assessment between our doctors later on .

THE END
Finally: I would like to thank everyone for reading this lecture and

Very extremely unstoppable continuous aggressive thanks to saleh al-qadi for pictures.

Done by: Muntaser Ghassan Toffaha.

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