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Radiography of Facial Bones ( Orbits /Nasal bones/ Optic foramina) (Mandible/ TMJs & Zygomatic Arch) Facial Bones (Orbits) Basic Lateral Parietoacanthial (Waters) 15OF ( Caldwell ) Special Horizontal lateral ( Trauma ) Modified Waters Achanthioparietal (Reverse Waters) Facial Bones (Optic Foramina) Basic Parietoorbital ( Rhese ) Parietoacanthial (Waters) Special Modified Waters Facial Bones (Tempromandibular Joints) Basic AP Axial ( Modified Townes) Special Axiolateral 15Oblique ( Law) Axiolateral ( Schuller) Facial Bones (Nasal Bones) Basic Lateral Parietoacanthial Special Superoinferior ( Axial) Facial Bones (Mandible) Basic Axiolateral PA 0and 2025Cephalic AP Axial ( Townes) Special Submentoertex Facial Bones (Zygomatic Arches) Basic Submentovrtex (SMV) Oblique Inferosuperior AP Axial (Modified Townes) Parietoacanthial ( Waters) Lateral Facial Bones Exposure factors KV mAs 85 40 FFD Focus Grid 100 Fine Yes Film/Screen combination Regular Patient Position Patient recumbent semi prone or sits erect facing the bucky, Part Position Rotate head to the side in question Align Interpupillary line perpendicular to bucky surface Align midsagittal plane parallel to bucky surface Adjust chin to bring infraorbitomeatal line perpendicular to film holder Use radiolucent support under chin Climate within the facial bones Suspend respiration during exposure Central Ray Perpendicular to film holder Centre Point 31 To Zygoma (midway between outer canthus and EAM) Anatomy Demonstrated Superimposed, mandible, orbits, maxilla and Zygoma Greater wings of sphenoid 32 Parietoacanthial (Waters) Exposure factors KV 80 mAs 40 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient prone or sits erect facing the bucky. Part Position Extend neck and rest chin against the bucky surface. Adjust head until mento Meatal line perpendicular to plane of bucky Align midsagittal plane perpendicular to and in line with the midline of bucky. Prevent rotation and tilting of the head Collimate to outer margins of skull on all sides Suspend respiration 33 Facial Bones OM Patient Position Central Ray Horizontally & perpendicular to film holder Centre Point Exit at acanthion Anatomy Demonstrated Zygoma, maxilla, inferior orbital margin, inferior portion of frontal bone, maxillary, ethmoid and frontal sinuses, nasal spine and septum 34 Facial Bones OM Anatomy Facial Bones15PA( Caldwell See Page 40) Lateral Facial Bones (Trauma) Exposure factors KV mAs 85 40 FFD Focus Grid 100 Fine Yes 35 Film/Screen combination Regular Patient Position The patient lies supine on the trolley or x-ray table Part Position the midsagittal plane aligned to the long axis of the trolley Interpupillary line parallel to the floor. The cassette is supported alongside the affected side of the face parallel to the midsagittal plane. the chin is raised to bring the orbital Meatal line vertical. Central Ray Horizontally & perpendicular to film holder Centre Point To a point midway between the outer canthus of the aye and the EAM. Anatomy Demonstrated Facial bones (superimposed) roof of orbits, Zygoma and mandible Facial Bones (Modified Waters) Exposure factors KV 80 mAs 40 FFD 100 Focus Fine 36 Grid Yes Film/Screen combination Regular Patient Position Patient prone or sits erect facing the bucky. Part Position Extend neck resting chin and nose against the bucky surface. Adjust head until lips- Meatal line perpendicular to plane of bucky OML forms a 55with bucky plane Align midsagittal plane perpendicular to and in line with the midline of bucky. Prevent rotation and tilting of the head Collimate to outer margins of skull on all sides Suspend respiration Central Ray Horizontally & perpendicular to film holder Centre Point Exit at acanthion Anatomy Demonstrated Zygoma, maxilla, inferior orbital margin, inferior portion of frontal bone, maxillary, ethmoid and frontal sinuses, nasal spine and septum Orbital floors & Less distorted view of the entire orbital rims Achanthioparietal (Reverse Waters) ( Trauma ) Exposure factors KV 80 mAs 40 FFD 100 Focus Fine 37 Grid Yes Film/Screen combination Regular Patient Position The patient lies supine on the table Part Position Midsagittal plane aligned central to the top The chin is depressed until the orbital Meatal line is at 90 degrees to the trolley top, A small pad may be needed below the occipital bone to achieve this comfortably. The Interpupillary line should be parallel to the trolley top. Central Ray 20cephalic Centre Point To mid maxilla Anatomy Demonstrated Inferior orbital margin, maxilla, nasal bones, Zygoma and Zygomatic arches Facial Bones (Nasal Bones) Basic Lateral Parietoacanthial ( Waters method ; see p. 59 ) Special Superoinferior ( Axial) 38 Lateral Nasal bones Exposure factors KV mAs 55 3-4 FFD Focus Grid 100 Fine Yes Film/Screen combination Regular Patient Position The patient sits erect facing the erect film The patient can be examined in semi prone position Part Position the head is turned so that the side of the face is in contact with the bucky median sagittal plane parallel to the film Interpupillary line parallel to the floor. This position requires the patient to sit upright as close as possible to the bucky. Central Ray Perpendicular to film holder Centre Point ½ inch inferior to Nasion Anatomy Demonstrated 39 Nasal bone and associated soft tissue structures. Nasofrontal suture Anterior nasal spine Nasal Bones Superoinferior (Axial) Exposure factors KV mAs FFD Focus 40 Grid Film/Screen combination 60 6 100 Fine Yes Regular Patient Position The patient lying in the prone position on table Part Position Place angled support under film holder Extend and rest chin on film holder as demonstrated below Adjust film perpendicular to Glabelloalveolar line Align median sagittal plane to mid line and perpendicular to film holder Collimate on all sides to nasal bones Suspend respiration during exposure. Central Ray Perpendicular to film holder Centre Point To Nasion Anatomy Demonstrated Tangential projection of mid nasal and distal nasal bones and nasal soft tissue Facial Bones (Optic Foramina) Basic Parietoorbital ( Rhese ) Parietoacanthial (Waters see page 59 ) Special Modified Waters ( see page 62 ) 41 Parietoorbital (Rhese) Exposure factors KV 80 mAs 40 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient prone or sits erect facing the bucky. Part Position Position patient chin, cheek, and nose against table/upright bucky surface. Adjust head so that the midsagittal plane forms a 53 angle with bucky Align acanthiomeatal line perpendicular to plane of bucky Collimate on all sides to obtain ailed size of 4 inches square Prevent rotation and tilting of the head Suspend respiration during exposure This projection sometimes referred to as a (Three point landing position ) (Chin, cheek and nose) Central Ray perpendicular to film holder Centre Point To down side orbit Anatomy Demonstrated 42 Cross section of each optic canal Nondistorted view of the optic foramin projected into the lower outer quadrant of orbit Facial Bones (Mandible) Basic Axiolateral PA 0and 2025Cephalic AP Axial ( Townes) Special Submentoertex 43 Axiolateral Mandible Exposure factors KV 75 mAs 25 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient supine or sits erect Part Position Place head in a lateral position with side of interest contact with film holder If possible have patient close mouth and bring teeth together Extend neck to prevent cervical spine superimposition by chin Rotate head in an oblique direction ( the degree of rotation depends on area of mandible to be demonstrated - Head in true lateral best demonstrates Ramus - 30rotation towards bucky demonstrates Body - 45rotation best demonstrates mentum - 10to15rotation best provide general survey of mandible collimate n all sides of mandible Suspend respiration during exposure Central Ray Angled 25cephalad Centre Point Angle of mandible Anatomy Demonstrated 44 Body and Ramus of mandible closet to the film. Mandible Rt. oblique Radiograph PA 0and 2025Cephalic Exposure factors KV mAs FFD Focus 45 Grid Film/Screen combination 75 25 100 Fine Yes Regular Patient Position Patient supine or sits erect Part Position Dentures and oral jewellery should be removed. The patient sits erect facing the bucky, Midsagittal plane in the midline of the film, Coronal plane parallel to the film Interpupillary line parallel to the floor. The chin is lowered to bring the OML at 90 degrees to the film collimate on all sides of mandible Suspend respiration during exposure Central Ray PA : perpendicular to film holder PA Axial angle central ray 2025Cephalic Centre Point For PA exit at junction of lips For axial PA exit at acanthion Anatomy Demonstrated Mandibular rami and the body superimposed on the cervical spine. 46 PA Mandible AP Axial Mandible ( Towens) 47 Patient Position Same description as Townes for cranium ( Page ---- ) Part Position Same description as Townes for cranium ( Page ---- ) Collimate to mandible including TMJs Central Ray Angled 35to 40Caudally centre Point To Glabella ( mid way between EAMs and angles of mandible Submentovertix Mandible Same descripton as SMV for cranium( Page ---) in addition to Collimation to mandible area Centre point 4 cm inferior to mandibular symphysis Entire mandile with coronoid and condyloid processes will be visulized Facial Bones (Tempromandibular Joints) Basic AP Axial ( Modified Townes) Special Axiolateral 15Oblique ( Law) Axiolateral ( Schuller) 48 AP Axial ( Modified Towens ) Exposure factors KV mAs 85 40 FFD Focus Grid 100 Fine Yes Film/Screen combination Regular .Patient Position Patient supine or sits erect AP against the bucky Part Position Align midsagittal plane perpendicular to and in line with the midline of bucky and central ray. Tuck chin in to bring the OML 90to film. Collimate on all sides to region of interest Suspend respiration during exposure Projections must be taken with open and closed mouth for comparison Central Ray Angled 35Caudally from OML Or 42Caudally from IOML centre Point 49 2 inches anterior to EAMs ( 1 inch anterior to level of TMJs) Anatomy Demonstrated Condyloid processes of mandible and Tempromandibular fossa TMJs Axiolateral 15Oblique (Law) Parietoorbital (Rhese) Exposure factors 50 KV 80 mAs 40 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient prone or sits erect Part Position Rest lateral aspect of head against bucky surface . Move patients body in an oblique direction for patient comfort Maintain Interpupillary line perpendicular to film holder From lateral rotate face towards bucky surface 15 Collimate on all sides to obtain field size about 4 inches square Suspend respiration during exposure Projections must be taken with open and closed mouth for comparison Central Ray 15caudad Centre Point 4 cm superior to upside EAM Anatomy Demonstrated Tempromandibular joint nearst the film is visible with out superimposition of opposite TMJ and without superimposition by cervical spine Close mouth image demonstrates condyle within mandibular fossa 51 In open mouth the condyles moves to the anterior margin of the mandibular fossa Axiolateral ( Schuller) Patient Position Patient prone or sits erect Part Position Rest lateral aspect of head against bucky surface . Adjust head into a true lateral position Maintain Interpupillary line perpendicular to film holder Align MSP parallel with film holder Collimate on all sides to obtain field size about 4 inches square Suspend respiration during exposure Projections must be taken with open and closed mouth for comparison Central Ray 25to 30caudad Centre Point 5 cm superior to upside EAM Facial Bones (Zygomatic Arches) Basic Submentovrtex (SMV) Oblique Inferosuperior( Tangential) AP Axial (Modified Townes) 52 Parietoacanthial ( Waters) Zygomatic arches (SMV) Exposure factors KV mAs 65 6-10 FFD Focus Grid 100 Fine Yes Film/Screen combination Regular Patient Position Patient supine or sits erect, with his back to the bucky Part Position .Take care with this technique; it is not suitable for trauma patients a small pillow is placed behind the shoulders and the patient extends the neck until the orbital Meatal baseline is parallel to the film the Interpupillary line parallel to the floor and the median sagittal plane at 90 degrees to the film Apply thyroid protection with lead rubber Collimate to outer margin of Zygoma Central Ray Horizontally & perpendicular to film holder 53 Centre Point Midway between Zygomatic arches ( 4 cm inferior to Mandibular symphysis Anatomy Demonstrated Zygomatic arches projecting laterally from each Zygomatic and temporal bone Oblique Inferosuperior( Tangential) Exposure factors 54 KV mAs FFD Focus Grid 65 6-10 100 Fine Yes Film/Screen combination Regular Patient Position Patient supine or sits erect, with his back to the bucky Part Position .Rest chin, hyper extending neck until IOML is parallel to film holder Rest head on vertex of skull Rotate head 15towards side to be examined Also tilt chin 15towards side of interest Collimate on all sides to within 1 inch of Zygomatic bone and arches Zygomatic bone Zygomatic Arch Temporal bone Central Ray Horizontally & perpendicular to film holder Centre Point Zygomatic arch of interest Anatomy Demonstrated Single Zygomatic arch free from superimposition with parietal bone or mandible Radiography of Para nasal sinuses/Mastoids & temporal bones 55 Para nasal Sinuses Basic Lateral PA ( Caldwell) Parietoacanthial (Waters) Special Submentovrtex (SMV) Parietoacanthial trans oral (Open mouth Waters) Mastoids Basic Axiolateral oblique ( Modified law) Axiolateral oblique ( Stenvers) AP Axial ( Townes) Special Axiolateral ( Schuller) Axiolateral oblique ( Reverse Stenvers) Temporal Bones / Petrous Pyramids Basic AP Axial ( Townes ) Submentovrtex (SMV) Para nasal Sinuses (PNS) Basic Lateral PA ( Caldwell) Parietoacanthial (Waters) Special Submentovrtex (SMV) Parietoacanthial trans oral 56 Lateral PNS Exposure factors KV mAs 85 40 FFD Focus Grid 100 Fine Yes Film/Screen combination Regular Patient Position Patient erect facing the bucky, Part Position Rotate head to the side in question, to bring the median Sagittal plane parallel to the film. Adjust head into a true lateral position The Interpupillary line should be perpendicular to film holder Suspend respiration during exposure Central Ray Perpendicular to film holder 57 Centre Point Mid way between outer canthus and EAM Anatomy Demonstrated Sphenoid sinuses Superimposed frontal , ethmoid and maxillary sinuses Sella turcica Superimposed orbits Note Erect lateral with horizontal beam is essential to demonstrate air-fluid level Otherwise horizontal lateral is recommended Allow a short time with patient erect for the fluid to settle PA PNS (Caldwell) Exposure factors 58 KV mAs FFD Focus Grid 75 50 100 Fine Yes Film/Screen combination Regular Patient Position Patient erect facing the bucky, Part Position Place patient nose and forehead against upright bucky Adjust neck extended to elevate OML 15from horizontal Adjust midsagittal plane perpendicular to midline Suspend respiration during exposure Collimate to area of sinuses If bucky can be tilted15the patient forehead and nose can e supported directly to bucky with OML perpendicular to the bucky surface Central Ray Perpendicular to film holder Centre Point Mid way between outer canthus and EAM Anatomy Demonstrated Frontal sinuses Anterior ethmoid air cells Parietoacanthial (Waters) Exposure factors KV mAs FFD Focus 59 Grid Film/Screen 75 50 100 Fine Yes combination Regular Patient Position Patient erect facing the bucky, Part Position Extend neck placing chin and nose against upright bucky Adjust head until mento Meatal line (MML) is perpendicular to bucky OML form a 37angle with the plane of bucky Adjust midsagittal plane perpendicular to midline Suspend respiration during exposure Collimate to area of sinuses Central Ray Perpendicular to film holder Centre Point Mid way between outer canthus and EAM Anatomy Demonstrated Maxillary sinuses free from superimposition with petrous ridge Oblique view of the frontal sinuses PNS Submentovrtex (SMV) Exposure factors KV mAs FFD Focus 60 Grid Film/Screen 75 50 100 Fine Yes combination Regular Patient Position sits erect, with his back to the stand bucky Part Position Raise chin , hyper extending neck if possible until IOML parallel to table Head rest on vertex of skull Align midsagittal plane perpendicular to mid line of bucky Apply thyroid protection with lead rubber Ensure no rotation or tilt Suspend respiration during exposure Central Ray Perpendicular to IOML Centre Point Midway between the angles of the mandible (2 inches inferior to Mandibular symphysis) Anatomy Demonstrated Sphenoid sinuses Ethmoid sinuses Nasal fossa Maxillary sinuses PNS Parietoacanthial trans oral (Open mouth Waters) Exposure factors 61 KV mAs FFD Focus Grid 75 50 100 Fine Yes Film/Screen combination Regular Patient Position Patient erect facing the bucky, Part Position Extend neck placing chin and nose against upright bucky Adjust head until mento Meatal line (MML) is perpendicular to bucky OML form a 37angle with the plane of bucky Adjust midsagittal plane perpendicular to midline Ask patient to open mouth by dropping jaw without moving head Centre cassette to acanthion Suspend respiration during exposure Collimate to area of sinuses Central Ray Perpendicular to film holder Centre Point Mid way between outer canthus and EAM Anatomy Demonstrated Maxillary sinuses free from superimposition with petrous ridge Sphenoid sinuses through the open mouth Oblique view of the frontal sinuses Mastoids Basic Axiolateral oblique ( Modified law) Axiolateral oblique ( Stenvers) AP Axial ( Townes) Special 62 Axiolateral ( Schuller) Axiolateral oblique ( Reverse Stenvers) Axiolateral oblique (Modified law) Exposure factors KV 75 mAs 25 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient prone or sits erect Part Position Rest lateral aspect of head against bucky surface. Tape auricle forward to avoid superimposing mastoid Move patients body in an oblique direction for patient comfort Maintain Interpupillary line perpendicular to film holder From lateral rotate face towards bucky surface 15 Suspend respiration during exposure Examine both sides for comparison Collimate closely to field size approximately 4 inches square Central Ray 15caudad Centre Point 63 Exit at down side mastoid tip ( 1 inch posterior and superior to up side EAM Anatomy Demonstrated Lateral perspective of the mastoid air cells and bony labyrinths nearest film Axiolateral oblique ( Stenvers) Exposure factors KV 75 mAs 25 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient prone or sits erect Part Position Adjust chin to bring IOML perpendicular to film holder Tape auricle forward to avoid superimposing mastoid Move patients body in an oblique direction for patient comfort Rotate head 45With the side of interest downside Align downside mastoid region to film centre Suspend respiration during exposure Examine both sides for comparison Collimate closely to field size approximately 4 inches square 64 Central Ray 12cephalad Centre Point 3-4 inches posterior and ½ inch inferior to upside EAM Anatomy Demonstrated Petrous pyramids in profile The bony labyrinth The tympanic cavity Internal auditory canal and mastoid air cells with mastoid tip 65 Mastoids AP Axial ( Townes) Exposure factors KV mAs 75 25 FFD Focus Grid 100 Fine Yes Film/Screen combination Regular .Patient Position Patient supine or sits erect A.P. against the bucky Part Position Align midsagittal plane perpendicular to and in line with the midline of bucky and central ray. Tuck chin in to bring the OML 90to film. Collimate to outer margin of skull Suspend respiration during exposure Central Ray Angled 30caudad to OML or 37To IOML Angled 30Caudally for anterior clinoid processes Centre Point 2 inches above Glabella Anatomy Demonstrated Dorsum sella and posterior clinoids in foramen magnum Bilateral petrous pyramids Mastoid air cells and boy labyrinth 66 Mastoids Special views Axiolateral (Schuller) Exposure factors KV 75 mAs 25 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient semi prone erect or recumbent Part Position Rest lateral aspect of head against bucky surface. Tape auricle forward to avoid superimposing mastoid Move patients body in an oblique direction for patient comfort Maintain Interpupillary line perpendicular to film holder Align midsagittal plane parallel to film holder Suspend respiration during exposure Examine both sides for comparison Collimate closely to field size approximately 4 inches square Central Ray 25to 30caudad Centre Point 1 ½ inch superior and posterior to upside EAM Anatomy Demonstrated Lateral perspective of the mastoid air cells & bony labyrinths nearest film Condoyle of mandible and TMJ visualized anterior to mastoid air cells 67 Mastoids Axiolateral oblique ( Reverse Stenvers) Exposure factors KV 75 mAs 25 FFD 100 Focus Fine Grid Yes Film/Screen combination Regular Patient Position Patient erect or supine Part Position Rotate head 45away from side of interest. Adjust chin bringing IOML perpendicular to bucky surface Align elevated mastoid region to film centre Suspend respiration during exposure Examine both sides for comparison Collimate closely Central Ray 10caudad Centre Point 1 inch anterior and ¾ inch superior to elevated EAM Anatomy Demonstrated Elevated side petrous ridge Elevated side TMJ visualized anterior to mastoid air cells 68 Temporal Bones / Petrous Pyramids Basic AP Axial ( Townes ) See Page 41 Submentovrtex (SMV) See page 45 Review Questions A/ Name the lines& planes illustrated in the diagrams below ----------------------------- -------------------------------- ---------------------------- ----------------------------- 69 ------------------------ ---- ------------------------- B/ Circle the most suitable answer The Anthropological line 1. The Isometric “Baseline” which runs from the inferior orbital margin to the upper border of the external auditory Meatus (EAM) 2. The line connects the centres of the orbits and is at 90 degree to the median sagittal plane. 3. This line passes at 90 degrees to the anthropological line through the centre of the external auditory meatus. The Orbital- Meatal Line 1. The Isometric “Baseline” which runs from the inferior orbital margin to the upper border of the external auditory Meatus (EAM) 2. The line connects the centres of the orbits and is at 90 degree to the median sagittal plane 3. The original “Baseline” which runs from the Nasion through the outer canthus of the eye to the centre of the external auditory meatus. All the following are cranial bones except 1. Lacrimal bones 2. frontal and occipital bones 3. Parietal bone The towens (AP Axial Skull) well demonstrates 1. maxillary sinuses 2. occipital bone 3. base of skull The submentovertical projection well demonstrates 1. the frontal bone 2. the orbits 3. the skull base All Para nasal sinuses well demonstrated in 1. lateral projection 2. oblique projection 3. towens projections 70 The Skull is made up of eight cranial bones 1. Nasal, Lacrimal, Maxillary, Zygomatic, Palatine, Nasal, Vomer and Mandible. 2. Frontal, Occipital, (Right & Left) Parietal, Ethmoid, Sphenoid, and ( Right & Left) Temporal 3. Frontal, Occipital, Parietal, Ethmoid, Sphenoid, Temporal, Maxillary, and Zygomatic. 4. Frontal, Occipital, Parietal, Ethmoid, Sphenoid, Temporal, Zygomatic, and Glabella In the PA axial skull (Caldwell) projection the central ray angulation is 1. 12 degrees caudally 2. 10 degrees caudally 3. 15 degrees caudally 4. 20 degrees caudally In positioning orbits we use what anatomical landmarks? 1. 2. 3. 4. Forehead, nose, and chin Forehead, nose, and Zygoma Nose, chin, and jaw Zygoma, nose, and chin When imaging the Mastoid process many things should be taken in Consideration. 1. High-resolution imaging system must be used with perfect film screen contact and clean screens. 2. Use the smallest possible field size, and a complete head immobilization. 3. A small Focal Spot no larger than 0.6 mm, and folded the ear forward 4. All of the above Mastoid study should be performed in the upright position? 1. True 2. False 71 C/ List the central ray ¢re point for the following projections below Projection Central ray Waters Caldwell Towens Axiolateral (Schuller) for mastoid air cells Submento vertical Lateral sella turcica PA mandible 72 Centre point