154 PART II Imaging

TABLE 9-1 Technical Aspects of Extraoral Radiographic Projections and Resultant Images
LATERAL CEPH SMV WATERS PA CEPH REVERSE TOWNE

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
of patient
placement

Illustration
of patient
placement

Skull view

Resultant
image

superimpositions and distortions and facilitates identification of as well. These methods are not the only approach to examining
anatomic landmarks. Interpreting poor-quality images can lead to radiographic images. Any technique that reliably ensures that the
diagnostic errors and subsequent treatment errors. entire image will be examined is equally appropriate.
The first step in the interpretation of radiographic images is the
identification of anatomy. A thorough knowledge of normal radio-
graphic anatomy and the appearance of normal variants is critical
LATERAL SKULL PROJECTION (LATERAL
for the identification of pathology. Abnormalities cause disrup- CEPHALOMETRIC PROJECTION)
tions of normal anatomy. Detecting the altered anatomy precedes Of the extraoral radiographs described in this chapter, the lateral
classifying the type of change and developing a differential diag- cephalometric projection is the most commonly used in dentistry.
nosis. What is not detected cannot be interpreted. All cephalometric radiographs, including the lateral view, are taken
Interpretation of extraoral radiographs should be thorough, with a cephalostat that helps maintain a constant relationship
careful, and meticulous. Images should be interpreted in a room among the skull, the film, and the x-ray beam. Skeletal, dental, and
with reduced ambient light, and peripheral light from the viewbox soft tissue anatomic landmarks delineate lines, planes, angles, and
or monitor should be masked. A systematic, methodical approach distances that are used to generate measurements and to classify
should be used for the visual exploration or interrogation of the patients’ craniofacial morphology. At the beginning of treatment,
diagnostic image. A method for the visual interrogation of extra- these measurements are often compared with an established stan-
oral radiograph of the head and neck is illustrated for the lateral dard; during treatment, the measurements are usually compared
and PA projections but can be applied to the remaining projections with measurements from previous cephalometric radiographs of
 C H A P T E R 9 Extraoral Projections and Anatomy 165

Lateral PA Reverse Oblique Lateral

Ceph SMV Waters Ceph Towne Body Ramus Panoramic

Anterior mandible
Mandibular body
Low usefulness
Ramus
Medium usefulness
Coronoid process
High usefulness
Condylar neck No symbol: not recommended
Condylar head
AREA OF INTEREST

Anterior maxilla
Posterior maxilla
Orbit
Zygoma
Zygomatic arch
Nasal bones
Nasal cavity
Maxillary sinus
Frontal sinus
Ethmoid sinus

Sphenoid sinus

FIGURE 9-10 Relative usefulness of extraoral radiographic projections to display various anatomic structures.

Figure 9-10 summarizes the use of extraoral radiographs for the Keats TE, Anderson MW: Atlas of normal roentgen variants that may
evaluation of various anatomic structures. Although panoramic simulate disease, ed 9, St Louis, 2012, Mosby.
radiography is the subject of Chapter 10, it is included in Figure Long BW, Ballinger PW, Smith BJ, et al: Merrill’s atlas of radiographic
9-10 for comparison. positions and radiologic procedures, vol 2, ed 11, St Louis, 2007, Mosby.
Miyashita K: Contemporary cephalometric radiography, Tokyo, 1996,
Although most extraoral radiographs in dentistry are cephalo-
Quintessence Publishing Co.
metric projections obtained for orthodontic and orthognathic
Shapiro R: Radiology of the normal skull, Chicago, 1981, Year Book
assessment of asymptomatic patients, anatomic variants that can Medical Publishers.
simulate disease or affect treatment or even occult pathology can Swischuk LE: Imaging of the cervical spine in children, New York, 2001,
be identified. As such, cephalometric radiographs should be viewed Springer-Verlag.
as skull radiographs first, and interpreted following a systematic,
thorough, and knowledgeable approach.

BIBLIOGRAPHY
Kantor ML, Norton LA: Normal radiographic anatomy and common
anomalies seen in cephalometric films, Am J Orthod Dentofac Orthop
91:414–426, 1987.
 C H A P T E R 10 Panoramic Imaging 179

A
1 10 7
6 18
2 8 9
14 15 16
4 20
11 12 17
5 13 22
3 21
19
23
29
24
28
30
25 25
27 30
B 26 L
1. Pterygomaxillary fissure 11. Floor of the nasal cavity 22. Coronoid process
2. Posterior border of maxilla 12. Anterior nasal spine 23. Posterior border of ramus
3. Maxillary tuberosity 13. Incisive foramen 24. Angle of mandible
4. Maxillary sinus 14. Hard palate/floor of the nasal cavity 25. Hyoid bone
5. Floor of the maxillary sinus 15. Zygomatic process of the maxilla 26. Inferior border of mandible
6. Medial border of maxillary sinus/ 16. Zygomatic arch 27. Mental foramen
lateral border of the nasal cavity 17. Articular eminence 28. Mandibular canal
7. Floor of the orbit 18. External auditory meatus 29. Cervical vertebrae
8. Infraorbital canal 19. Styloid process 30. Epiglottis
9. Nasal cavity 20. Mandibular condyle
10. Nasal septum 21. Sigmoid notch

FIGURE 10-18 A, Properly acquired and displayed panoramic image of an adult patient. The patient’s left side is indicated on the
image, and the image is oriented as if the clinician were facing the patient. This is the same orientation used with a full-mouth series,
making it easier for the clinician to orient himself or herself and to interpret the image. B, Drawing of the same panoramic radiograph
identifying midfacial and mandibular anatomic structures.

• Maxillary sinuses teardrop appearance; it is very important to identify this area on

• Zygomatic complex, including inferior and lateral orbital rims, both sides of the image because maxillary sinus mucoceles and
zygomatic process of maxilla, and anterior portion of zygo- carcinomas characteristically destroy the posterior maxillary border,
matic arch which is manifested as loss of the anterior border of the pterygo-
• Nasal cavity and conchae maxillary fissure. Also, Le Fort fractures of the maxilla by defini-
• TMJ (also viewed in the mandible, but visualizing important tion involve the pterygoid plates, and a Le Fort fracture often is
structures multiple times is always a good idea in image initially diagnosed by disturbances of the integrity of the pterygo-
interpretation) maxillary fissure on the panoramic image. These disturbances may
• Maxillary dentition and supporting alveolus be the only evidence for such a fracture on the panoramic image.
Examining the cortical outline of the maxilla is a good way to To clarify the three-dimensional anatomy of the pterygomaxillary
center the examination of the midface. The posterior border of the fissure, Figure 10-19 shows this structure in a dried skull, in an
maxilla extends from the superior portion of the pterygomaxillary axial CT image, and in the panoramic image.
fissure down to the tuberosity region and around to the other side. The maxillary sinuses are usually well visualized on panoramic
The posterior border of the pterygomaxillary fissure is the ptery- images. The clinician should identify each of the borders (poste-
goid spine of the sphenoid bone (the anterior border of the ptery- rior, anterior, floor, roof) and note whether they are entirely out-
goid plates). Occasionally, the sphenoid sinus may extend into this lined with cortical bone, roughly symmetric, and comparable in
structure. The pterygomaxillary fissure itself has an inverted radiographic density. The borders should be present and intact.