imaging of oral and maxillofacial

1. Dr.Huda Moutaz Ismail
Department of oral & maxillofacial surgery
University of Baghdad /college of dentistry
Diagnostic imaging in oral & maxillofacial surgery

2. Diagnostic imaging classified in to :
A-Non invasive imaging which include
1- plain radiographic (conventional)
2-Computed tomography (CT)
3-Magnetic resonance imaging (MRI)
4-Contrast enhanced imaging (sialography ,arthrography )
5-Ultrasonography
6- Nuclear Imaging (SPECT, PET …)

3. B-Invasive imaging:
This is performed for diagnostic as well as
therapeutic purpose
This include :
-Angiography
-Angioplasty
-Embolization
-Calculus destruction ,others…
Before embolization (left); immediately after embolization
(middle); and, 12 months following embolization (right). Angiography

4. Non invasive imaging technique :
1-plain conventional radiograph
A-intra-oral radiograph :
A-Periapical
B-Bite-wing
C-Occlusal include : >> Maxilla (occlusal view )
-Mandible (occlusal view )
- Upper standard occlusal -Upper oblique occlusal
-Vertex occlusal
Lower 90° occlusal Lower 45° occlusal Lower oblique occlusal

5. B-Extra oral radiography :
• Standard occipitomental (0° OM)
• 30° occipitomental (30° OM)
• Postero-anterior of the skull (PA skull)
sometimes referred to as occipitofrontal (OF)
• Postero-anterior of the jaws (PA jaws)
• Reverse Towne's
• Submento-vertex (SMV)
• Transcranial
• Transpharyngeal.
-Lateral radiographs of the head and jaws are
divided into:
• True laterals
• Oblique laterals
• Bimolars (two oblique laterals on one film).

6. Lateral jaw projection (lateral oblique projection).
Key words :
•To Examine the posterior region of the mandible, impacted teeth ,lesions, fracture etc..
•Valuable in children, or Senile patients who can’t withstand intraoral films or unconscious
patient.
-Cassette is positioned flat against the cheek and centered over the mandibular first molar
area.
-Head position is tilted about 10 to 20 degree toward the side to be examined
and the chin is protruded.
Oblique lateral radiographic of # of the left body and angle.

7. Lateral skull (cephalometric )projection:
This projection shows the skull vault and facial skeleton from the lateral aspect.
Purpose : Conditions affecting the sella turcica, • Fractures of the cranium and the
cranial base • Investigation of the frontal, sphenoidal and maxillary sinuses
Chromophobe adenoma; pituitary
adenoma
Sella turcica (lateral
projection): destruction by
tumour

8. Submandibular sialolith
Eagles' syndrome

9. Bimolar technique
Bimolar is the term used for the radiographic projection
showing oblique lateral views of the right and left sides of the
jaws on the different halves of the same radiograph.

10. Standard occipitomental (0° OM)
Water’s view projection (sinus projection)
Key points :
-Purpose: To Evaluate the maxillary , frontal and ethmoid sinuses ( paranasal sinus).
-Detect middle third fractures (Le fort I,II,III) , Coronoid process fractures
Note : The patient facing the film with the head tipped back so the radiographic baseline
is at 45° to the film, The X-ray central ray horizontal (0°) centred through the occiput
Le fort II fracture

11. Occipito Mental 30° (OM30) View Standard occipitomental (0° OM)
the head tipped back, radiographic
baseline at 45° to the film, the central ray
at 30° to the horizontal.
the head tipped back, radiographic
baseline at 45° to the film, the central
ray at 0 to the horizontal.

12. Key points :
-This projection shows the skull vault, primarily the frontal bones and the jaws.
-The beam passes through the skull in a posterior to anterior direction.
Purpose: Asymmetry , Developmental abnormalities ,fracture of the skull vault.
• Conditions affecting the cranium, particularly:
— Paget's disease
— Multiple myeloma
— Hyperparathyroidism
Note : The X-ray tubehead is positioned with the central ray horizontal (0°) centred through the occiput
Posteroanterior skull (PA) projection:
Asymmetry

13. Posteroanterior radiographic view of
a fracture of the left body and angle.
Postero-anterior of the jaws
(PA jaws/PA mandible)
Purpose : • Fractures of the mandible ,lesions such as cyst
or tumor in post 1/3 of body & in ramus of mandible
,condylar hypoplasia or hyperplasia
The PA view is used to evaluate the entire mandible. However, the
symphysis is often obscured by the cervical spine, and the condyles
can be superimposed over the mastoid process and occipital bone. A
Waters view or a basal view should be obtained to better evaluate
the symphysis to negate the overlap of the cervical spin.
Note :The X-ray tubehead is again horizontal (0°), but now the central ray is
centred through the cervical spine at the level of the rami of the mandible

14. Reverse –towne projection
Key points:
This projection shows the condylar heads and necks.
Purpose to examine fractures of the condylar neck of the mandible ,Condylar
hypoplasia or hyperplasia..

15. Submentovertex projection
Key words : This projection shows the base of the skull, sphenoidal sinuses and facial skeleton
from below.
Purpose :
• Destructive lesions affecting the palate, pterygoid region or base of skull
• Investigation of the sphenoidal sinus
• Assessment of the thickness (medio-lateral) of the posterior part of the mandible before
osteotomy
• Fracture of the zygomatic arches

16. Lateral Transcranial View of TMJ
Main indications
The main clinical indications include:
• TMJ pain dysfunction syndrome and internal
derangements of the joint producing pain,
clicking and limitation in opening
• To investigate the size and position of the disc
— this can only be inferred indirectly from the
relative positions of the bony elements of the
joints

17. Transpharyngeal
Main indications
The main clinical indications include: TMJ pain dysfunction syndrome
To investigate the presence of joint disease, particularly osteoarthritis and rheumatoid
Arthritis ,to investigate pathological conditions affecting the condylar head, including
cysts or tumours ,fractures of the neck and head of the condyle.

18. Disadvantage of conventional plain radiograph :
-Ionizing radiation (X ray)
-Two dimensional image of 3D object
-Superimposition
- It can't detect early pathology unless at least 30% of mineral is
changed
Test yourself
-Patient with fracture mandible
Imaging modalities ?
-fracture of zygomatic arch
Imaging modalities ?

19. 2- computed tomography (CT scan) or computed axial tomography (CAT scan)
Key points:
-Introduced in 1974 by Sir Jeffrey Hounsfield
-A CT image is a computer-generated picture based on multiple x-ray exposures taken around the
periphery of the subject.
-It is made in variety of planes (axial ,coronal ,sagittal ) ,Most CT is done in the axial Plane.
-Slice thickness is usually 5 mm through the head and neck, unless three dimensional
reconstruction is anticipated. In such cases, the slice thickness
is 1.0 to 1.5 mm in order to provide adequate data.
- It take 20-30 min

20. -The images are usually viewed in two modes: bone windowing and soft-tissue windowing.
- Bone windowing > contrast is set > so the osseous structures visible in max details
-Soft-tissue windowing, the bone looks uniformly white, but various types of soft tissues can be
distinguished
Windowing allows the CT scan reader to focus on certain tissues within a CT scan that fall
within set parameters.

21. What Is Bright
on CT?
• Blood
• Contrast
• Bone
• Calcium
• Metal
• Why?
What Is Dark
on CT?
•Air
•CSF/H20
•Fat
•Why?
What is gray =?
The denser the object, the whiter it is on CT

22. This ability to block x-rays as they pass through a substance is known as
attenuation.

23. Substance HU
Air −1000
Lung −500
Fat −84
Water 0
CSF 15
Blood +30 to +45
Muscle +40
Soft Tissue, Kontrastmittel +100 to +300
Bone
+700(cancellous bone)to +3000
(dense bone)
The HU of common substances
The Hounsfield scale applies to medical grade CT scans
but not to cone beam computed tomography (CBCT) scans
(the x ray attenuation value of ct scan are scored )

24. Purpose : CT is typically used to evaluate
(1) The extent of lesions suspected or detected with other radiographic techniques,
(2) In maxillofacial Trauma
(3) Evaluation of the paranasal sinuses & salivary glands
(4) In evaluation of dental implant site
5) Cervical L.N & neck masses
Note : CT is rarely indicated for evaluation of the TMJ since the osseous structures can
be visualized adequately with less expensive techniques such as conventional
tomography or panoramic radiography, and disk displacement and other joint soft-tissue
information can be better obtained with magnetic resonance imaging.

25. Fracture
osteosarcoma

26. CT scan
Fan beam
Helical CT (HCT)
Key points
-bone , soft tissue
& air window
Cone beam
(CBCT)
Types of CT Scanners
Computed tomography can be divided into 2 categories based on acquisition
x-ray beam geometry; namely: fan beam and cone beam

27. Multiplanar reconstruction
Multiplanar reconstruction (MPR) is the
simplest method of reconstruction. A volume is
built by stacking the axial slices. The software
then cuts slices through the volume in a different
plane (usually orthogonal). As an option, a
special projection method, such as maximum-
intensity projection (MIP) or minimum-intensity
projection (mIP), can be used to build the
reconstructed slices

28. Contrast Ct scan:
Contrast media/dye is a special fluid introduced into the body. It is used to
“highlight” the area of the body being scanned.
Intravenous injection  through a vein to highlight blood vessels & other structures
It is an iodine-based dye.
Orally taken for an abdomen CT scan (drink 2-3 glasses of oral contrast 20-30 min
before the scan.
Case : Aneurysmal bone cyst
A. Cropped panoramic radiograph shows that the lesion grows largely and the internal septa show
multilocular soap bubble appearance five months later. B. Coronal contrast enhanced CT scan shows an expansile,
multilocularosteolytic lesion with multiple internal septation and multiple fluid levels within cystic spaces at the left mandible.

29. False positives/negatives
CT findings should not be interpreted in isolation, and scans should always be read in
conjunction with clinical and endoscopic findings because of high rates of false-positive results.
Up to 40% of asymptomatic adults have abnormalities on sinus CT scans, as do more than 80%
of those with minor upper respiratory tract infections.

30. CT angiography
A CT Angiography (CTA) is a minimally invasive technique that
helps physicians diagnose and treat medical conditions.
Angiography uses one of three imaging technologies:
-X-rays with catheters
-Computed tomography (CT)
-Magnetic Resonance Imaging (MRI)
A CT angiogram is a less invasive procedure than a standard
angiogram. A traditional angiogram procedure involves inserting
a catheter through artery; while with a CT angiogram exam no
catheters or tubing is involved.
- During a CT angiogram. A special dye (contrast material)
painlessly injected into the veins using an IV in your arm or hand.

31. Computed Tomographic Arteriography (CTA)
with 3D reconstruction gives us the advantages
of contrast arteriography
Fig. . CT angiography (64 slices, GE Healthcare
Technologies) of a maxillofacial AVM for treatment
planning. In- and outflow can be clearly differentiated,
the maxilla is not destroyed.

32. Magnetic resonance imaging (MRI)
It use electrical and magnetic fields and
radiofrequency (RF) pulses, rather than ionizing radiation
to produce an image.
Key points :
-The patient is placed within a large circular magnet
that causes the hydrogen protons of the body to be aligned
with the magnetic field.
-It acquire image in 3 planes
Two distinct views are typically generated:
T1 and T2. Adipose tissue has the highest signal in the T1-weighted
image, and this view is often used for identifying anatomic structures
water appearing darker and fat brighter.
By comparison, the T2 image highlights tissues with high water
content and is especially useful in depicting inflammatory processes
and neoplasms. fat is differentiated from water, but in this case fat
shows darker, and water lighter, eg. in the case of cerebral and spinal
study, the CSF (cerebrospinal fluid) will be lighter in T2-weighted
images

33. -The typical MRI examination of the TMJ consists of both
closed- and open-mouth views in an oblique sagittal plane.
-MRI key points :
--In dentistry, the primary uses of MRI have been
the evaluation of various pathologic lesions (such as
tumors) and the assessment of the TMJ, salivary
glands .
-To define the extension of soft T tumor
-To distinguish fluid from tumor in Paranasal sinus
-Relationship of major B.V to S.T tumor
-visualize the anatomy of cranial nerves

34. Figure. (A) CT of a patient with maxillary sinus cancer demonstrates bony destruction, (arrow) a
hallmark of malignancy. (B) MRI in the same patient more accurately distinguishes between the
intermediately enhancing tumor (long arrow) lining the maxillary sinus and the non-enhancing
secretions (short arrow) filling the maxillary sinus.

36. Figure 1. MRI and autopsy midcondyle anatomy of normal
temporomandibular joint: upper left oblique sagittal MRI, upper right
oblique coronal MRI, lower left oblique sagittal section, lower right oblique
coronal section (Maxillofacial Imaging.2006[28]

38. The major disadvantage of MRI
-Very loud continuous hammering noise when operating
-Some people are too big to fit inside the magnet
- Long periods of time ... up to 90 minutes
-Cost
-Contraindicated for certain patients,
Eg/patient with cardiac pacemakers, due to interference by
the electrical and magnetic fields. Patients with ferromagnetic metallic objects in strategic
places (such as aneurysm clips in the brain and metallic fragments in the eye) also should
not be placed in the magnet.
-Some patients feel claustrophobic inside the magnet and
may need to be sedated for the procedure.

39. in this figure Coronal pre- (A) and postgadolinium (B) T1-weighted MR images of the ABC. Note
the contrast enhancement of intracystic septae.
Contrast MRI
MRI contrast agents may be administered by IV injection
or orally, depending on the subject of interest
-The most commonly used compounds
for contrast enhancement are gadolinium-based.
-Used for enhancement of vessels in MR angiography or for brain tumor ,For large vessels
such as the aorta and its branches, the gadolinium(III) dose can be as low as 0.1 mmol per
kg body mass. Higher concentrations are often used for finer vasculature

40. Gadolinium ion (highly magnetizable) chelated to a molecule that won’t
pass an intact blood-brain barrier
Makes T1-weighted images brighter where it accumulates and makes
T2- and T2*-weighted images darker
Figure 5. Preoperative Gadolinium-enhanced T1-weighted MRI. Locally
advanced tumor (arrow) in the base of the tongue invaded the epiglottis
(arrow head).

41. magnetic resonance (MR) angiography
is an alternative to conventional angiography and
CT angiography, eliminating the need for iodinated
contrast media and ionizing radiation
-Non contrast enhanced MR angiography
A variety of techniques can be used to generate the
pictures, such as administration of a paramagnetic contrast
agent (gadolinium) or using a technique known as "flow-
related enhancement", where most of the signal on an
image is due to blood that recently moved into that plane

42. Nuclear Medicine
Key points:
-Radionuclide imaging is the technique of producing diagnostic images by analyzing the
radiation emitted from a patient who has previously been given radioactive medications
-Nuclear medicine differs from most other imaging modalities in that the tests primarily
show the physiological function
-It is based on the cellular function and physiology, rather than relying on physical
changes in the tissue anatomy
This is done by injecting certain radioactive compounds into the patient that have an
affinity for particular tissues — so-called target tissues.
Several radioisotopes are used in conventional nuclear medicine, depending on the tissue
under investigation
Eg/ Technetium (99mTc) — salivary glands, thyroid, bone, blood, liver, lung and heart

43. Main indications for conventional isotope imaging in the head and
neck
• Tumour staging — the assessment of the sites and extent of bone
metastases
• Investigation of salivary gland function, particularly in Sjogren's
syndrome
• Evaluation of bone grafts
• Assessment of continued growth in condylar hyperplasia
• Investigation of the thyroid
• Brain scans and assessment of a breakdown of the blood-brain
barrier.

44. Single Photon Emission Computed Tomography
(SPECT) /Key points:
• Single photon emission computed tomography (SPECT), where the
photons (gamma rays) are emitted from the patient and detected by a
gamma camera rotating around the patient 360 and the distribution of
radioactivity is displayed as a cross-sectional image or SPECT scan enabling
the exact anatomical site of the source of the emissions to be determined.
- Acquiring rotating delayed static images, generally sixty-four projections over 360º
-SPECT offers the possibility to widen the observational time window (owing to the
longer half life of single photon emitters) thus allowing biomedical scientists to observe
biological processes in vivo several hours or days after administration of the labeled
compound
SPECT

45. Nuclear Medicine
Tc-99m Radioactive decay Gamma ray/photon emission
(140KeV)
Gamma camera
Image

46. Positron Emission Tomography (PET)
(PET) is a nuclear medical imaging technique that detect alterations in biochemical processes
that suggest disease before changes in anatomy are apparent with other imaging tests, such
as CT or MRI.
-Radionuclides used in PET scanning are typically isotopes with short half-lives such as
carbon-11 (~20 min), nitrogen-13 (~10 min), oxygen-15 (~2 min), fluorine-18 etc... These
radionuclides are incorporated either into compounds normally used by the body such as
glucose (or glucose analogues), water, or ammonia, or into molecules that bind to receptors or
other sites of drug action. Such labelled compounds are known as radiotracers.
-the most commonly used radiotracer in clinical PET scanning is fluorodeoxyglucose
18F) 18F-FDG or FDG,.(it is used in > 95% of PET scan )
To conduct the scan, a short-lived radioactive tracer isotope is injected into the living subject (usually into blood circulation).
The tracer is chemically incorporated into a biologically active molecule. There is a waiting period while the active molecule
becomes concentrated in tissues of interest; then the subject is placed in the imaging scanner. The molecule most commonly
used for this purpose is fluorodeoxyglucose (FDG), a sugar, for which the waiting period is typically an hour. During the scan a
record of tissue concentration is made as the tracer decays.

47. Positron Emission Tomography - PET
Radionuclide with excess protons
Decay
Positrons
Positron + electron collision
Annihilation reaction generates two 511-keV
gamma photons
PET detector ring for localization & imaging

48. -PET can give false results if a patient's chemical balances are
not normal. Specifically, test results of diabetic patients or
patients who have eaten within a few hours prior to the
examination can be adversely affected because of blood sugar
or blood insulin levels.
-limitation is inability to provide information about exact
localization of the lesion because lack of anatomic landmarks
-Radioactive substance IV 30 to 90 minutes for the
substance to travel and accumulate in the tissue .After that
time, scanning begins. This may take 30 to 45 minutes.
-PET detects area of increased metabolic activity as
indicated by uptake of radioactive glucose (tumor,
infection)
Cancerous tissue, which uses more glucose than normal tissue, will
accumulate more of the substance and appear brighter than normal
tissue on the PET images

49. PET/CT : is hybrid system
-Combined functional imaging of PRT & anatomical imaging
of CT scan
-More accurate staging
-More Accurate Surgical Planning
-More Accurate Guided Biopsy
-More Accurate RT Planning
-Monitoring response to therapy & post operative recurrence
Fig. 9. (a) CT; (b) FDG; (c) FDG PET/CT. Intense FDG uptake due to a Warthin's tumour within the
left parotid gland (arrow).

50. Fig. 3. Mouth floor carcinoma
T4N2M0 invaded the tongue and
alveolar region of the mandible.
(A) Sagittal PET; (B) sagittal CT,
reconstruction of HRCT; (C) sagittal
PET/CT fusion; (D) sagittal image
of the involved lymph nodes, PET;
(E) CT; (F) PET/CT fusion.

51. Figure 5 Large cell lymphoma in a patient who
presented with a shallow ulcer in the hard
palate. Axial fused PET/CT image shows a large
focus of abnormally increased FDG uptake in
the hard palate (arrow), a finding that is
suggestive of squamous cell carcinoma.
However, histologic analysis of a biopsy
specimen demonstrated non-Hodgkin large cell
lymphoma.

52. Carcinoma of the tongue T1N0M0. (A, B) Primary staging,
PET/CT; (C, D)
restaging after partial glossectomy 6 months previously
showing local recurrence in the resection line and in the oral cavity
bottom.

53. • Figure 2. An 83-year-old woman with a history of squamous cell carcinoma of the left mandible. The
patient was staged as N0 on clinical examination. 18F-FDG-PET and CT obtained preoperatively. The
primary tumor is hypermetabolic (top arrow). There are multiple hypermetabolic foci in the left cervical
region corresponding to levels 1, 2, 3, and 4 lymph nodes (middle and bottom arrows). Composite
resection of the left mandible and neck was performed 2 weeks after the imaging study. Pathology on the
composite resection specimen revealed 35 of 40 lymph nodes positive for metastatic cancer.Nahmias et al.
PET/CT Staging in Oral/Head and Neck Cancer. J Oral Maxillofac Surg 2007.
•

54. Reccurent mouth floor carcinoma. Highly increased 18F-FDG was found
in tumorous tissue, the mild increase in 18F-FDG accumulation is in the
overused styloglossus muscle. (A) Axial PET/CT fusion; (B) coronal
PET/CT fusion; (C) sagittal PET/CT fusion.

55. Scintigraphy is a form of diagnostic test used in nuclear medicine, wherein radioisotopes
(here called radiopharmaceuticals) are taken internally, and the emitted radiation is
captured by external detectors (gamma cameras) to form two-dimensional images. In
contrast, SPECT and positron emission tomography (PET) form 3-dimensional images,
and are therefore classified as separate techniques to scintigraphy, although they also use
gamma cameras to detect internal radiation.
Bone scintigraphy
evaluate for metastatic bone cancer, primary bone tumor , evaluate the extent of
osseous inflammation , osteomyelitis., arthritis ,to evaluate abnormal metabolism
or growth in the skeleton (metabloic disorder) …
Bone scans (scientigraphy) -Most common Technetium-99m which has a 6 hour half life with
good detector , with MDP
NORMAL BONE SCAN”
Over 3-4 hrsMDP (HDP) is accumulatedin
the bonesand in thelesions proportional
to Blood Flow and to Osteoblastic
ActivityExcretionof

56. Normal results
The normal appearance of the scan will vary according to the
patient's age. In general, a uniform concentration of radionuclide
uptake is present in all bones in a normal scan.
Areas that absorb little or no amount of tracer appear
as dark or "cold" spots. Areas of fast bone growth or
repair absorb more tracer and show up as "hot" spots in
the pictures.
.
Abnormal results
Bone
scanning
Hot spots
uptake
Cold spots
uptake TYPICAL “HOT”SPOTBONE SCANS
METASTATIC PROSTATE CANCER
Metastasis: “cold”Lesion Prostate Cancer

57. A 73-y-old woman, affected by multiple myeloma, previously
treated with bisphosphonates. (A) Orthopantomography showed
area of bone cortical irregularity (circled) in right mandible. (B)
Three-phase bone scanning revealed increased blood pool
(circled). (C) Hybrid SPECT/CT allowed definition of area of
osteonecrosis (arrow) with neighboring hyperactive viable bone.
Bone Scintigraphy and SPECT/CT of
Bisphosphonate-Induced Osteonecrosis of the Jaw

58. Ultrasonography
U- Ultrasound > 20 kHz; / for medical usage typically 2-10 MHz
This is a noninvasive and relatively inexpensive
technique for imaging
The probe converts electrical energy in to high frequency sound waves
Which pass in to tissue of different densities
The vibration energy of US is reflected back to the scanning
transducer Where the sound converting in to image
Reflection of US wave by different tissue :
-Fluid  pass without reflection
-bone & lung All are reflected and not allowed to pass
-Soft tissue  Waves are partly pass
Ultrasonography is most useful in the evaluation of deeply
seated masses and is often helpful in distinguishing
a solid mass from one that is cystic.
Regarding head and neck region it is used to evaluate
-Salivary glands
-Lymph node

60. Dual-energy x-ray absorptiometry (DEXA)
First, obtain plain radiographs if a decrease in bone mineral density is suspected
Osteopenia may be apparent as radiographic lucency but is not always noticeable until
30% of bone mineral is lost
Plain radiography is not as accurate as BMD testing (bone mineral density )
Devices that measure BMD include:
-Quantitative computed tomography
-Dual-energy x-ray absorptiometry (DEXA)
-Quantitative ultrasonography
-Radiogrammetry
Dual energy x-ray absorptiometry (DXA) scan of edentulous person. Regions
of interest are superimposed over maxilla and mandible and bone mineral
density calculated with computer software.

61. DEXA : Dual-energy x-ray absorptiometry requires less radiation, is less expensive,
and has better reproducibility than quantitative computed tomography
-The DEXA machine uses a special, low, dose x- ray.
-It has become the standard method for determining bone density.
-This method can be used in both adults and children
-Results are reported as two values, T and Z scores
T-score'.
your bone density compares to the normal average for young, healthy adults whose
bone density is at its peak.
A T-score of 0 means your bones are the same density as an average young.
- 0 and -1 indicates the bone density is normal
-Between -1 and -2.5 indicates bone density is below normal, or osteopenia
-Below -2.5 indicates osteoporosis

62. sialography
-Conventional sialography >>>
-Used for evaluating the ductal system of the major salivary glands
-Contrast medium is injected into the major duct of the salivary gland of interest ,
It is also contraindicated during acute infection because of possible exacerbation.
There is a modality CT sialography & MRI sialography.

63. Sialography
Equipments
1.Sialographiccannulas – tips ranging from 0.012 – 0.033.
2.Lacrimal dilators.
3.5ml / 10 ml syringe.
4.Contrast media
5.Secretogauges – fresh lemon etc
-(about 0.7 ml for the parotid gland, 0.5 ml for the submandibular gland).

64. Lateral-oblique conventional sialographic
image obtained after MR sialography confirms
the diagnosis of sialolithiasis and shows the
distal displacement of the calculus (long
straight arrow) caused by active filling of the
ductal system. Bartholin duct (curved arrow)
and primary (large arrowhead), secondary
(small arrowheads), and tertiary branches
(short straight arrow) are slightly dilated. The
calculus was removed endoscopically.

65. Figure 1: Sialogram of the right and left parotid glands with juvenile
recurrent parotitis demonstrates sialectasis (arrow) on the panoramic
radiograph

66. Normal Sialographic Appearance of the Parotid Gland
The main duct is of even diameter (1-2 mm wide) filled completely.
The duct structure within the gland branches -regularly and tapers gradually
towards the periphery of the gland, the so-called tree in winter appearance
Sialographic appearances of sialadenitis
Dots or blobs of contrast medium within the gland , an appearance known as
sialectasis caused by the inflammation of the glandular tissue producing
saccular dilatation of the acini.

67. MRI sialography
Key points :
-Non invasive technique (not requiring cannulation )
-No contrast ( saliva act as a contrast media )
-No radiation
But
the spatial resolution of these techniques remains limited when compared
with X-ray
techniques in the evaluation of the branch ducts and the morphological
changes of early sialectasis.
-MR imaging was performed at least 4 hours after contrast-enhanced digital
sialography to allow normal salivation to wash away air bubbles. ( sometimes
the air bubbles are inadvertently injected with the contrast material)
-Prior to MR imaging, the patients were given lemon juice or sialogogue to
stimulate salivation, because saliva act as contrast media

68. Parotid duct strictures - MR sialography
Dilated left parotid duct with mutiple
strictures (arrows)
Heavily T2 ( T2W fat-suppression sequence)
-Heavy T2 weighting was achieved  On T2-weighted
turbo spin-echo MR images, saliva in the salivary ductal
system was hyperintense, and sialoliths were
hypointense.
- Thus, heavily T2-weighted sequences were the first
choice in MR sialography.
-An MR sialogram was acquired in an oblique sagittal
orientation, others .

69. • Discrepancy in imaging features of the parotid glands
between MR sialography and conventional sialography.
A–J, MR sialograms (A–E) and conventional sialograms (F–J) of
the parotid glands in xerostomia patients with or without
Sjögren’s syndrome: grade 0 (A and F), grade 1 (B and G),
grade 2 (C and H), grade 3 (D and I), and grade 4 (E and J).
Note apparent differences in sialographic features at grade 4
(E versus J).

70. Thank you