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CHAPTER

Extraoral Projections
and Anatomy
Sotirios Tetradis and Mel L. Kantor
9
OUTLINE
Selection Criteria Posteroanterior Skull Projection (Posteroanterior Waters Projection
Technique Cephalometric Projection) Reverse-Towne Projection (Open-Mouth)
Evaluation of the Image Submentovertex (Base) Projection Conclusions
Lateral Skull Projection (Lateral Cephalometric
Projection)

I
n extraoral radiographic examinations, both the x-ray source clearly. This usually is done by placing a metal marker (an R or an
and the image receptor (film or electronic sensor) are placed L) on the outside of the cassette in a corner in which the marker
outside the patients mouth. This chapter describes the most does not obstruct diagnostic information.
common extraoral radiographic examinations in which the source The proper exposure parameters depend on the patients size,
and sensor remain static. These include the lateral cephalometric anatomy, and head orientation; image receptor speed; x-ray source-
projection of the sagittal or median plane; the submentovertex to-receptor distance; and whether or not grids are used. In cases
(SMV) projection of the transverse or horizontal plane; and the of known or suspected disease, medium-speed or high-speed rare-
Waters, posteroanterior (PA) cephalometric, and reverse-Towne earth screen-film combinations provide optimal balance between
projections of the coronal or frontal plane. Panoramic radiography diagnostic information and patient exposure. For orthodontic pur-
is described in Chapter 10, and other more complex imaging poses, high-speed combinations reduce patient exposure without
modalities are described in Chapters 11 through 14. compromising the identification of anatomic landmarks necessary
for cephalometric analysis. Although radiographic grids reduce
SELECTION CRITERIA scattered radiation and improve contrast and resolution, they result
in higher patient exposure. Cephalometry does not require the use
Extraoral radiographs are used to examine areas not fully covered of grids. However, grids could improve the radiographic appear-
by intraoral films or to evaluate the cranium, face (including the ance of fine structures, such as trabecular architecture, and aid in
maxilla and mandible), or cervical spine for diseases, trauma, or the diagnosis of disease.
abnormalities. Standardized extraoral (cephalometric) radiographs Proper positioning of the x-ray source, patient, and image
also assist in evaluating the relationship between various orofacial receptor requires patience, attention to detail, and experience.
and dental structures, growth and development of the face, or The main anatomic landmark used in patient positioning during
treatment progression. extraoral radiography is the canthomeatal line, which joins the
Before obtaining an extraoral radiograph, it is essential to evalu- central point of the external auditory canal to the outer canthus
ate the patients complaints and clinical signs in detail. The clini- of the eye. The canthomeatal line forms approximately a 10-degree
cian first must decide which anatomic structures need to be angle with the Frankfort plane, the line that connects the superior
evaluated and then select the appropriate projection or projections. border of the external auditory canal with the infraorbital rim.
Selecting the appropriate extraoral radiographic examination for The image receptor and patient placement, central beam direction,
the diagnostic task at hand is the first step in obtaining and inter- and resultant image for the lateral, submentovertex, Waters, pos-
preting a radiograph. For spatially localizing pathology, usually at teroanterior, and reverse-Towne projections are summarized in
least two radiographs taken at right angles to each another are Table 9-1 and are described in detail in the text. Table 9-1 is
obtained. organized to show the progressive head rotation in relation to
the x-ray beam in the frontal views and thus clarify the resultant
TECHNIQUE projected anatomy.

Extraoral radiographs are produced with conventional dental x-ray


machines, certain models of panoramic machines, or higher capac-
EVALUATION OF THE IMAGE
ity medical x-ray units. Cephalometric and skull views require at Extraoral images should first be evaluated for overall quality.
least a 20 cm 25 cm (8 inch 10 inch) image receptor. It is criti- Proper exposure and processing result in an image with good
cal to label the right and left sides of the image correctly and contrast and density. Proper patient positioning prevents unwanted

153
154 P AR T I I Imaging

T ABL E 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 HAP TE R 9 Extraoral Projections and Anatomy 155

Posterior Anterior Posterior


Pterygoid Pterygoid Pterygomaxillary clinoid Sella clinoid Sphenoid Planum maxillary Roof of
plates Clivus spine fissure processes turcica processes sinus sphenoidale sinus orbit

Ethmoid
Base of air cells
middle cranial
fossa Nasion
External Nasal bone
auditory
Lens of eye
meatus
Lower eyelid
Mastoid
air cells Frontal
process of
Mastoid zygoma
process
Inferior
Occipital rim of orbit
condyle
Floor of
Posterior orbit
arch of
atlas Zygomatic
process of
maxilla
Anterior
arch of Anterior
atlas nasal spine
Dens axis
Point A
Posterior
pharyngeal wall Hard
palate
Earlobe
Tooth bud

Salpingopharyngeal Point B
fold

Superior Soft Inferior border Dorsum of Hyoid bone


border of palate of zygomatic arch tongue
inferior
turbinate

FIGURE 9-1 Anatomic landmarks identified in the lateral cephalometric projection.

the same patient to monitor growth and development as well as less than the same structures on the side far from the image recep-
treatment. tor. Bilateral structures close to the midsagittal plane demonstrate
less discrepancy in size compared with bilateral structures farther
Image Receptor and Patient Placement away from the midsagittal plane. Structures close to the midsagittal
The image receptor is positioned parallel to the patients midsagit- plane (e.g., the clinoid processes and inferior turbinates) should be
tal plane. The site of interest is placed toward the image receptor nearly superimposed.
to minimize distortion. In cephalometric radiography, the patient
is placed with the left side toward the image receptor (U.S. stan- Interpretation
dards), and a wedge filter at the tube head is positioned over the Although the lateral cephalometric radiograph is obtained to eval-
anterior aspect of the beam to absorb some of the radiation and uate the relationship of the oral and facial structures, this radio-
allow visualization of soft tissues of the face. Additional informa- graph is still a lateral skull film providing significant diagnostic
tion about lateral cephalometry is provided at the end of this information for the head and neck anatomy. As such, lateral cepha-
section. lometric radiographs should first be evaluated for possible pathol-
ogy and for anatomic variants that might simulate disease, before
Position of Central X-Ray Beam cephalometric analysis. It is not sufficient to limit the interpreta-
The central beam is perpendicular to the midsagittal plane of the tion to the cephalometric analysis. To ensure that all anatomic
patient and the plane of the image receptor and is centered over structures are assessed, a systematic visual interrogation of lateral
the external auditory meatus. cephalometric radiographs should be followed. Such an approach
is presented next (Fig. 9-2):
Resultant Image (Fig. 9-1) Step 1. Evaluate the base of the skull and calvaria. Identify the
Exact superimposition of right and left sides is impossible because mastoid air cells, clivus, clinoid processes, sella turcica, sphe-
the structures on the side near to the image receptor are magnified noid sinuses, and roof of the orbit. In the calvaria, assess vessel
156 P AR T I I Imaging

A B C

D E F

FIGURE 9-2 Interrogating the lateral cephalometric projection. The radiograph in the upper left demonstrates the whole image.
Subsequent radiographs correspond to the steps of interrogation.

grooves, sutures, and diploic space. Look for intracranial finding in young patients but can cause narrowing of the airway
calcifications. and breathing difficulties. Finally, partial agenesis of the ring
Step 2. Evaluate the upper and middle face. Identify the orbits, of atlas (Fig. 9-3, F ) is a developmental anomaly that can cause
sinuses (frontal, ethmoid, and maxillary), pterygomaxillary fis- instability of the atlanto-occipital and atlanto-odontoid articula-
sures, pterygoid plates, zygomatic processes of the maxilla, tion and requires further evaluation. The fusion of the body
anterior nasal spine, and hard palate (floor of the nose). Evalu- and transverse process of the dens with the third cervical ver-
ate the soft tissues of the upper and middle face, nasal cavity tebrae (see Fig. 9-3, F ), which is a rare normal variant, should
(turbinates), soft palate, and dorsum of tongue. also be noted.
Step 3. Evaluate the lower face. Follow the outline of the mandible: After evaluation of the whole lateral skull radiograph for pos-
from the condylar and coronoid processes; to the rami, angles, sible pathology, cephalometric evaluation of the patient follows.
and bodies; and finally to the anterior mandible. Evaluate the There are many cephalometric analyses based on a variety of
soft tissue of the lower face. anatomic landmarks. Steiner and Ricketts analyses are two com-
Step 4. Evaluate the cervical spine, airway, and area of the neck. monly used analyses that employ the skeletal, dental, and soft
Identify each individual vertebra, confirm that the skull-C1 and tissue landmarks listed in Box 9-1. Precise identification of the
C1-C2 articulations are normal, and assess the general align- various landmarks on the lateral cephalometric radiograph is nec-
ment of the vertebrae. Assess soft tissues of the neck, hyoid essary to generate accurate cephalometric measurements. The
bone, and airway. landmarks in Box 9-1 are shown in Figure 9-4, A, on a side view
Step 5. Evaluate the alveolar bone and teeth. of a skull and in Figure 9-4, B, on a 5-mm-wide midline section
Figure 9-3 presents incidental findings identified on lateral of an orthodontic patient imaged by cone-beam computed tomo-
cephalometric radiographs of asymptomatic orthodontic patients. graphic imaging. Finally, Figure 9-4, C, depicts the projected
Calcification of the intraclinoid ligament and formation of a landmark position on the lateral cephalogram of an orthodontic
bridged sella is a common normal variant that does not warrant patient.
any further evaluation (Fig. 9-3, A). Alternatively, expansion,
irregular outlines, and destruction of the sella floor (Fig. 9-3,
B) raise suspicion of an invasive lesion, such as a pituitary
tumor, and require further investigation with advanced imaging
POSTEROANTERIOR SKULL PROJECTION
and referral to a medical specialist. Multiple opacities throughout (POSTEROANTERIOR CEPHALOMETRIC PROJECTION)
patients calvaria are the result of superimposed hair braids The second most common skull radiograph used in dentistry is the
(Fig. 9-3, C). Well-defined opacities at the superior aspect of PA cephalometric projection. The PA cephalogram is mainly used
the calvaria represent calcifications of arachnoid granulations for evaluation of facial asymmetries and for assessment of orthog-
and are a normal variant (Fig. 9-3, D). Enlargement of the nathic surgery outcomes involving the patients midline or
pharyngeal adenoids and palatal tonsils (Fig. 9-3, E) is a common mandibular-maxillary relationship.
C HAP TE R 9 Extraoral Projections and Anatomy 157

A B

C D

E F

FIGURE 9-3 Incidental findings on lateral cephalometric radiographs of asymptomatic orthodontic patients are indicated by arrows.
A, Intraclinoid ligament calcification appearing as a bridged sella. B, Irregular and erosive expansion of the floor and anterior and posterior
walls of sella turcica. C, Hair braid shadows are superimposed over the patients calvaria. D, Calcification of arachnoid granulations is a
normal variant. E, Enlarged pharyngeal adenoids and palatal tonsils can be a normal finding depending on the patients age but can
compromise nasal breathing. F, Cervical spine anomalies, such as agenesis of the posterior ring of atlas (C1) (arrow), can cause spine
instability, whereas vertebrae fusion of dens (C2) and C3 (arrowhead) is a normal variant.
158 P AR T I I Imaging

B C

FIGURE 9-4 A, Anatomic cephalometric landmarks shown on a side view of the skull. B, Midline anatomic cephalometric landmarks
depicted on a 5-mm-wide cone-beam computed tomographic section of an orthodontic patient. C, Cephalometric landmarks used in Steiner
and Ricketts cephalometric analyses (see Box 9-1).
C HAP TE R 9 Extraoral Projections and Anatomy 159

BOX 9-1 Definition of Cephalometric Landmarks


SKELETAL LANDMARKS 26. L6 mesial cusp: Tip of the mandibular first molar mesial buccal cusp
1. Porion (P): Most superior point of the external auditory canal 27. L6 mesial: Contact point on the mesial surface of the mandibular first molar
2. Sella (S): Center of the hypophyseal fossa 28. L6 distal: Contact point on the distal surface of the mandibular first molar
3. Nasion (N): Frontonasal suture 29. Ul incisal: Incisal edge of maxillary central incisor
4. Orbitale (O): Most inferior point of the infraorbital rim 30. Ul facial: Most convex point of the buccal surface of the maxillary central incisor
5. PT point: Most posterior point of the pterygomaxillary fissure 31. Ul root: Root tip of the maxillary central incisor
6. Basion (Ba): Most anterior point of the foramen magnum 32. LI incisal: Incisal edge of mandibular central incisor
7. PNS: Tip of the posterior nasal spine 33. LI facial: Most convex point of the buccal surface of the mandibular central
8. ANS: Tip of the anterior nasal spine incisor
9. A point (A): Deepest point of the anterior border of the maxillary alveolar ridge 34. LI root: Root tip of the mandibular central incisor
concavity
SOFT TISSUE LANDMARKS
10. B point (B): Deepest point in the concavity of the anterior border of the
mandible 35. Soft tissue glabella: Most anterior point of the soft tissue covering the
11. Pogonion (Po): Most anterior point of the symphysis frontal bone
12. Gnathion: Midpoint of the symphysis outline between pogonion and menton 36. Soft tissue nasion: Most concave point of soft tissue outline at the bridge of
13. Menton (M): Most inferior point of the symphysis the nose
14. Gonion: Most convex point along the inferior border of the mandibular ramus 37. Tip of nose: Most anterior point of the nose
15. Ramus point: Most posterior point of the posteroinferior border of the 38. Subnasale: Soft tissue point where the curvature of the upper lip connects to the
mandibular ramus floor of the nose
16. R1: Most inferior point of the sigmoid notch 39. Soft tissue A point: Most concave point of the upper lip between the subnasale
17. R2: Arbitrary point on the lower border of the mandible below R1 and the upper lip point
18. R3: Most concave point of the anterior border of the mandibular ramus 40. Upper lip: Most anterior point of the upper lip
19. R4: Most convex point of the posterior border of the mandibular ramus 41. Stomion superius: Most inferior point of the upper lip
20. Articulare (Ar): Point of intersection between the basisphenoid and the posterior 42. Stomion inferius: Most superior point of the lower lip
border of the condylar head 43. Lower lip: Most anterior point of the lower lip
21. Condyle top: Most superior point of the condyle 44. Soft tissue B point: Most concave point of the lower lip between the chin and
22. DC point: Center of the condylar head lower lip point
45. Soft tissue pogonion: Most anterior point of the soft tissue of the chin
DENTAL LANDMARKS 46. Soft tissue gnathion: Midpoint of the chin soft tissue outline between the soft
23. U6 mesial cusp: Tip of the maxillary first molar mesial buccal cusp tissue pogonion and soft tissue menton
24. U6 mesial: Contact point on the mesial surface of the maxillary first molar 47. Soft tissue menton: Most inferior point of the soft tissue of the chin
25. U6 distal: Contact point on the distal surface of the maxillary first molar

See Figure 9-4.

Image Receptor and Patient Placement Interpretation


The image receptor is placed in front of the patient, perpendicular Similar to the lateral cephalometric projection, the PA cephalo-
to the midsagittal plane and parallel to the coronal plane. For the gram should be viewed as a skull film first, before any cephalomet-
PA cephalometric radiograph, the patient is placed so that the ric analysis. A systematic review of the radiograph, ensuring
canthomeatal line forms a 9-degree angle with the horizontal plane evaluation of all structures, should be followed. Such an approach
and the Frankfurt plane is perpendicular to the image receptor. For is presented next (Fig. 9-6):
the standard PA skull projection, the canthomeatal line is perpen- Step 1. Evaluate the calvaria, sutures, and diploic space starting in
dicular to the image receptor. the area of the left external auditory meatus, over the top of
the calvaria, to the right external auditory meatus. Look for
Position of Central X-Ray Beam intracranial calcifications. Identify the mastoid air cells and
The central beam is perpendicular to the image receptor, directed petrous ridge of the right and left temporal bones. In this and
from the posterior to the anterior (hence the name posteroante- all subsequent steps, compare the right and left sides and look
rior), parallel to the patients midsagittal plane, and is centered at for symmetry.
the level of the bridge of the nose. Step 2. Evaluate the upper and middle face. Identify the orbits,
sinuses (frontal, ethmoid, and maxillary), and zygomatic pro-
Resultant Image (Fig. 9-5) cesses of the maxilla. Assess the nasal cavity, middle and inferior
The midsagittal plane (represented by an imaginary line extending turbinates, nasal septum, and hard palate.
from the interproximal space of the central incisors through the Step 3. Evaluate the lower face. Follow the outline of the
nasal septum and the middle of the bridge of the nose) should mandible starting from the right condylar and coronoid
divide the skull image into two symmetric halves. The superior processes, ramus, angle, and body through the anterior man-
border of the petrous ridge should lie in the lower third of the dible to the left body, angle, ramus, coronoid process, and
orbit. condyle.
160 P AR T I I Imaging

Frontal Floor of
sinus sella turcica

Ethmoid
air cells
Superior
rim of orbit
Superior
orbital
fissure Lesser wing
of sphenoid

Lamina
Innominate
papyracea
line

Superior
border of Mastoid
petrous ridge process

Foramen
Antroethmoidal rotundum
septum
Pterygoid
process
Infraorbital
canal Base of
skull

Coronoid
process of Maxillary
mandible antrum

Inferior lateral Zygomatic


recess of process of
sphenoid sinus maxilla

Transverse
process Articulation
of atlas between atlas
and occipital
condyle
Articulation
between
atlas and axis

Nasal Intermaxillary Inferior


septum suture turbinate

FIGURE 9-5 Anatomic landmarks identified in the posteroanterior cephalometric projection.


C HAP TE R 9 Extraoral Projections and Anatomy 161

A B C

D E F

FIGURE 9-6 Interrogating the posteroanterior cephalometric projection. The radiograph in the upper left demonstrates the whole
image. Subsequent radiographs correspond to the steps of interrogation.

Step 4. Evaluate the cervical spine. Identify the dens, the superior symmetric halves. The buccal and lingual cortical plates of the
border of C2, and the inferior border of C1. mandible should be projected as uniform opaque lines. An under-
Step 5. Evaluate the alveolar bone and teeth. exposed view is required for the evaluation of the zygomatic arches
because they will be overexposed or burned out on radiographs
obtained with normal exposure factors.
SUBMENTOVERTEX (BASE) PROJECTION
Image Receptor and Patient Placement Interpretation
The image receptor is positioned parallel to the patients transverse As described earlier for the lateral and PA cephalometric projec-
plane and perpendicular to the midsagittal and coronal planes. To tions, a systematic approach that ensures interrogation of the com-
achieve this position, the patients neck is extended as far backward plete image and evaluation of all anatomic structures is paramount
as possible, with the canthomeatal line forming a 10-degree angle in the interpretation of the SMV projection.
with the image receptor.

Position of Central X-Ray Beam WATERS PROJECTION


The central beam is perpendicular to the image receptor, directed Image Receptor and Patient Placement
from below the mandible toward the vertex of the skull (hence the The image receptor is placed in front of the patient and perpen-
name submentovertex), and centered about 2 cm anterior to a line dicular to the midsagittal plane. The patients head is tilted upward
connecting the right and left condyles. so that the canthomeatal line forms a 37-degree angle with the
image receptor. If the patients mouth is open, the sphenoid sinus
Resultant Image (Fig. 9-7) is seen superimposed over the palate.
The midsagittal plane (represented by an imaginary line extending
from the interproximal space of the maxillary central incisors Position of Central X-Ray Beam
through the nasal septum, to the middle of the anterior arch of The central beam is perpendicular to the image receptor and cen-
the atlas, and to the dens) should divide the skull image into two tered in the area of the maxillary sinuses.
162 P AR T I I Imaging

Posterior wall of
maxillary sinus
Lateral wall
Coronoid
of orbit
process of
mandible
Nasal septum
Anterior
wall of Inferior orbital
middle fissure
cranial fossa
Sphenoid
sinuses
Ramus of
mandible
Lateral plate
of pterygoid
Foramen
process
ovale
Foramen Medial plate
spinosum of pterygoid
process
Clivus
Condyle of
Mandibular mandible
angle
Hyoid bone
External
auditory Posterior
meatus pharyngeal wall

Ossicles Anterior
arch of atlas
Occipital
condyle A
Dens

FIGURE 9-7 A, Anatomic landmarks identified in the submentovertex (SMV) projection. B, Underexposed SMV view reveals the
zygomatic arches.
C HAP TE R 9 Extraoral Projections and Anatomy 163

Nasal
septum
Frontal sinuses

Supraorbital
Palpebral canal
fissure
Zygomaticofrontal
Soft tissue suture
shadow
Innominate line
Infraorbital
margin Inferior orbital
foramen
Ala of nose
Superior orbital
Zygomatic fissure
bone
Foramen rotundum
Maxillary sinus Coronoid
process of
mandible

Sulcus for Zygomatic arch


superior posterior
alveolar artery Articular
in lateral wall of eminence of
maxillary sinus temporal bone

Condylar
head of mandible
Foramen ovale Sphenoid sinuses

FIGURE 9-8 Anatomic landmarks identified in the Waters projection.

Resultant Image (Fig. 9-8) Position of Central X-Ray Beam


The midsagittal plane (represented by an imaginary line extending The central beam is perpendicular to the image receptor and paral-
from the interproximal space of the maxillary central incisors lel to the patients midsagittal plane and is centered at the level of
through the nasal septum and the middle of the bridge of the the condyles.
nose) should divide the skull image into two symmetric halves.
The petrous ridge of the temporal bone should be projected below Resultant Image (Fig. 9-9)
the floor of the maxillary sinus. The midsagittal plane (represented by an imaginary line extending
from the middle of the foramen magnum and the posterior arch
Interpretation of the atlas through the middle of the bridge of the nose and the
As described earlier for the lateral and PA cephalometric projec- nasal septum) should divide the skull image in two symmetric
tions, a systematic approach that ensures interrogation of the halves. The petrous ridge of the temporal bone should be super-
complete image and evaluation of all anatomic structures is para- imposed at the inferior part of the occipital bone, and the condylar
mount in the interpretation of the Waters projection. heads should be projected inferior to the articular eminence.

Interpretation
REVERSE-TOWNE PROJECTION (OPEN-MOUTH) As described earlier for the lateral and PA cephalometric projec-
Image Receptor and Patient Placement tions, a systematic approach that ensures interrogation of the com-
The image receptor is placed in front of the patient, perpen- plete image and evaluation of all anatomic structures is paramount
dicular to the midsagittal plane and parallel to the coronal in the interpretation of the reverse-Towne projection.
plane. The patients head is tilted downward so that the can-
thomeatal line forms a 25-degree to 30-degree angle with the
image receptor. To improve the visualization of the condyles,
CONCLUSIONS
the patients mouth is opened so that the condylar heads are Extraoral radiography can provide valuable information for the
located inferior to the articular eminence. When requesting this evaluation of the dental and craniofacial complex. After assessing
image to evaluate the condyles, it is necessary to specify open- the patients signs and symptoms, the clinician should choose the
mouth, reverse-Towne; otherwise, a standard Towne view of the proper projection that provides the appropriate diagnostic infor-
occiput may result. mation for the evaluation of the anatomic structures in question.
164 P AR T I I Imaging

FIGURE 9-9 Anatomic landmarks identified in the open-mouth reverse-Towne projection.


C HAP TE 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: Merrills 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
91:414426, 1987.