Oral and Maxillofacial Radiology

ORAL & MAXILLOFACIAL
RADIOGRAPHY IN TRAUMA
Dr. Tahmasub Faraz Tayyab
Registrar
Oral & Maxillofacial Surgery
University Of Lahore
Pakistan

PLANES USED IN SKULL RADIOGRAPHY
The Median Sagittal plane.
 A vertical plane dividing the skull into 2 symmetrical
right and left halves when viewed from the anterior
aspect.
The Anthropological plane
 This plane splits the skull into upper and lower
halves passing along the anthropological baselines.
The Auricular plane
 This plane divides the skull into anterior and
posterior compartments along the Auricular lines.

Major body planes used in Skull radiography
MedianSagittal Auricular Anthropological

LINES USED IN SKULL RADIOGRAPHY
The Anthropological line
 The Isometric “Baseline” which runs from the inferior
orbital margin to the upper border of the external
auditory meatus (EAM)
The Orbital-Meatal Line
 The original “Baseline” which runs from the outer
canthus of the eye to the centre of the external auditory
meatus
The Interpupillary line
 The line connects the centres of the orbits and is at 90
degree to the median sagittal plane.
NOTE: there is a difference of 10 to 15 degrees between
the Orbital-Meatal line and the anthropological line.

PLAIN FILM RADIOGRAPHY
Facial series
 Standard occipitomental (0° OM)
 30° occipitomental (30° OM)
 Water’s view (PA view with cephalad angulation)
 (PA skull) sometimes referred to as occipitofrontal
(OF)
 Caldwell view (PA view)
 Submento-vertex (SMV)
 Jug Handle View
 Lateral Skull
 Upper Occlusal

PLAIN FILM RADIOGRAPHY
Mandible Series
 Lower Occlusal
 Panoramic Radiograph (OPG)
 Right & left lateral oblique view of mandible
 PA view of mandible
 Reverse Towne’s

STANDARD OCCIPITOMENTAL (0° OM)
 This projection shows the
facial skeleton and maxillary
antra, and avoids
superimposition of the dense
bones of the base of the skull.
 In this projection the petrous
bones are projected below the
maxillary antra so whole of the
lateral maxillary wall is clear.

MAIN INDICATIONS
 Detecting the following middle third facial fractures:
 LeFortI , Le Fort II & Le Fort III
 Zygomatic complex
 Naso-ethmoidal complex
 Orbital blow-out
 Coronoid process fractures
 Investigation of the frontal and ethmoidal sinuses
 Investigation of the sphenoidal sinus (projection
needs to be taken with the patient's mouth open).

TECHNIQUE AND POSITIONING
 The patient is positioned facing the film with the
head tipped back so the radiographic baseline is at
45° to the film, the so-called nose-chin position.
 The X-ray tube head is positioned with the central
ray horizontal (0°) centered through the occiput

30° OCCIPITOMENTAL (30° OM)
 This projection also shows
the facial skeleton, but from
a different angle to 0° OM,
enabling certain bony
displacements to be
detected.
 This projection provides a
superior view of the malar
arches and the anterior
aspect of the inferior orbital
margins.

MAIN INDICATIONS
 Detecting the following middle third facial fractures:
LeFortI
Le Fort II
Le Fort III
 Coronoid process fractures.

 The patient is in exactly the same position as for
the 0° OM, i.e. the head tipped back, radiographic
baseline at 45° to the film, in the nose-chin position.
 The X-ray tube head is aimed downwards from
above the head, with the central ray at 30° to the
horizontal, centered through the lower border of the
orbit

PA SKULL
 This projection shows
the skull vault,
primarily the frontal
bones and the jaws.

MAIN INDICATIONS
 Fractures of the skull vault
 Investigation of the frontal sinuses
 Conditions affecting the cranium, particularly:
Paget's disease
multiple myeloma
hyperparathyroidism
 Intracranial calcification.

head tipped forwards so that the forehead and tip of
the nose touch the film — the so-called forehead-
nose position. The radiographic baseline is
horizontal and at right angles to the film.
ray horizontal (0°) centered through the occiput and
aimed to exit at nasion .

OCCIPITOFRONTAL 15° -20° (CALDWELL)
 The Caldwell view is a caudally angled PA
radiograph of the skull, designed to better visualize
the paranasal sinuses, especially the frontal
sinuses.
 OF 0° (PA Skull): Petrous ridges completely
superimposed with orbits
 OF10°: Petrous ridges appears in the middle of the
orbit
 OF 30°: Petrous ridges appears just below the
orbital margins

head tipped forwards so that the forehead and tip of
the nose touch the film — the so-called forehead-
nose position. The radiographic baseline is
horizontal and at right angles to the film.
ray horizontal (15-20°) centered through the occiput
and aimed to exit at nasion .

WATER’S VIEW (PNS)
 This projection was a modification of OF projection
in order to obtain view of maxillary antra while
retaining a view of the frontal and ethmoid sinuses.
head tipped back so the radiographic baseline is at
37° to the film, the so-called nose-chin position.
 The X-ray tube head is aimed perpendicular to the
image receptor and centered in the area of
maxillary sinuses.

SUBMENTO-VERTEX (SMV)
 This projection
shows the base of
the skull, zygomatic
arches, sphenoidal
sinuses and facial
skeleton from
below.

MAIN INDICATIONS
 Destructive/expansive 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 — to show these
thin bones the SMV is taken with reduced exposure
factors.

 The patient is positioned facing away from the film. The
head is tipped backwards as far as is possible, so the
vertex of the skull touches the film. In this position, the
radiographic baseline, is vertical and parallel to the film.
 The X-ray tube head is aimed upwards from below the
chin, with the central ray at 5° to the horizontal, centered
on an imaginary line joining the lower first molars .
 Note: The head positioning required for this projection
means it is contraindicated in patients with suspected
neck injuries, especially suspected fracture of the
odontoid peg.

JUG HANDLE VIEW
 Same as that in
submentovertex.
 The exposure time
for the zygomatic
arch is reduced to
approximately one-
third the normal
exposure time for a
submentovertex
projection

TRUE LATERAL SKULL
 This projection shows the
skull vault and facial
skeleton from the lateral
aspect. The main difference
between the true lateral
skull and the true
cephalometric lateral skull
taken on the cephalostat is
that the true lateral skull is
not standardized or
reproducible. This view is
used when a single lateral
view of the skull is required
but not in orthodontics or
growth studies.

MAIN INDICATIONS
 Fractures of the cranium and the cranial base
 Middle third facial fractures, to show possible downward
and backward displacement of the maxillae
 Investigation of the frontal, sphenoidal and maxillary
sinuses
 Conditions affecting the skull vault, particularly:
Paget's disease
multiple myeloma
hyperparathyroidism
 Conditions affecting the sella turcica, such as: Tumor of
the pituitary gland in acromegaly.

 The patient is positioned with the head turned
through 90°, so the side of the face touches the
film. In this position, the sagittal plane of the head is
parallel to the film.
ray horizontal (0°) and perpendicular to the sagittal
plane and the film, centered through the external
auditory meatus .

UPPER OCCLUSAL
 Occlusal radiography is defined as those intraoral
radiographic techniques taken using a dental X-ray
set where the film packet or a small intra
Maxillary occlusal projections
 Upper standard occlusal (standard occlusal)
 Upper oblique occlusal (oblique occlusal)
 Vertex occlusal (vertex occlusal).oral cassette is
placed in the occlusal plane.

UPPER STANDARD OCCLUSAL
 This projection
shows the anterior
part of the maxilla
and the upper
anterior teeth.

MAIN INDICATIONS
 Periapical assessment of the upper anterior teeth,
especially in children but also in adults unable to tolerate
periapical films
 Detecting the presence of unerupted canines,
supernumeraries and odontomes
 As the midline view, when using the parallax method for
determining the bucco/palatal position of unerupted
canines
 Evaluation of the size and extent of lesions such as
cysts or tumors in the anterior maxilla
 Assessment of fractures of the anterior teeth and
alveolar bone. It is especially useful in children following
trauma because film placement is straightforward.

 The patient is seated with the head supported and
with the occlusal plane horizontal and parallel to the
floor
 The film packet, with the white (pebbly) surface
facing uppermost, is placed flat into the mouth on to
the occlusal surfaces of the lower teeth. The patient
is asked to bite together gently. The film packet is
placed centrally in the mouth with its long axis
crossways in adults and anteroposteriorly in
children.
 The X-ray tubehead is positioned above the patient
in the midline, aiming downwards through the
bridge of the nose at an angle of 65°-70° to the film
packet

UPPER OBLIQUE OCCLUSAL
 This projection
shows the
posterior part of
the maxilla and the
upper posterior
teeth on one side.

MAIN INDICATIONS
 Periapical assessment of the upper posterior teeth,
especially in adults unable to tolerate periapical
films
cysts, tumors or osteodystrophies affecting the
posterior maxilla
 Assessment of the condition of the antral floor
 As an aid to determining the position of roots
displaced inadvertently into the antrum during
attempted extraction of upper posterior teeth
 Assessment of fractures of the posterior teeth and
associated alveolar bone including the tuberosity.

floor.
 The film packet, with the white (pebbly) surface
facing uppermost, is inserted into the mouth on to
the occlusal surfaces of the lower teeth, with its
long axis anteroposteriorly. It is placed to the side of
the mouth under investigation, and the patient is
asked to bite together gently.
 The X-ray tubehead is positioned to the side of the
patient's face, aiming downwards through the
cheek at an angle of 65°-70° to the film,centring on
the region of interest

VERTEX OCCLUSAL
 This projection shows a plan view of the tooth
bearing portion of the maxilla from above. To obtain
this view the X-ray beam has to pass through a
considerable amount of tissue, delivering a large
dose of radiation to the patient.
 Main indication for this projecton is assessment of
the bucco/palatal position of unerupted canines.

floor.
 Film packet is inserted into the mouth on to the
occlusal surfaces of the lower teeth, with its long
axis anteroposteriorly and the patient is asked to
bite on to it.
 The X-ray tube head is positioned above the
patient, in the midline, aiming downwards through
the vertex of the skull. The main beam is therefore
aimed approximately down the long axis of the root
canals of the upper incisor teeth.

DISADVANTAGES
 The primary X-ray beam may be in direct line with
the reproductive organs.
 A relatively long exposure time is needed(about
1second) despite the use of intensifying screens.
 There is direct radiation to the pituitary gland and
the lens of the eye.
 If the X-ray beam is positioned too far anteriorly,
superimposition of the shadow of the frontal bones
may obscure the anterior part of the maxilla.

LOWER OCCLUSAL
 Mandibular occlusal projections
 Lower 90° occlusal (true occlusal)
 Lower 45 ° occlusal (standard occlusal)
 Lower oblique occlusal (oblique occlusal)

LOWER 90° OCCLUSAL
 This projection shows a plan
view of the tooth bearing
portion of the mandible and
the floor of the mouth.

MAIN INDICATIONS
 Detection of the presence and position of
radiopaque calculi in the submandibular salivary
ducts
 Assessment of the bucco-lingual position of
unerupted mandibular teeth
 Evaluation of the bucco-lingual expansion of the
body of the mandible by cysts, tumours or
osteodystrophies
 Assessment of displacement fractures of the
anterior body of the mandible in the horizontal
plane.

 The film packet, with the white (pebbly) surface facing
downwards, is placed centrally into the mouth, on to the
occlusal surfaces of the lower teeth, with its long axis
crossways. The patient is asked to bite together gently.
 The patient then leans forwards and then tips the head
backwards as far as is comfortable, where it is
supported.
 The X-ray tubehead is placed below the patient's chin, in
the midline, centring on an imaginary line joining the first
molars, at an angle of 90° to the film .
Note: The lower 90° occlusal is mounted as if the
examiner were looking into the patient's mouth. The
radiograph is therefore mounted with the embossed dot
pointing away from the examiner.

LOWER 45° OCCLUSAL
 T his projection is
taken to show the
lower anterior teeth
and the anterior part
of the mandible. The
resultant radiograph
resembles a large
bisected angle
technique periapical
of this region.

MAIN INDICATIONS
 Periapical assessment of the lower incisor teeth,
especially useful in adults and children unable to
tolerate periapical films
cysts or tumours affecting the anterior part of the
mandible
 Assessment of displacement fractures of the
anterior mandible in the vertical plane.

floor.
 The film packet, with the white (pebbly)surface
facing downwards, is placed centrally into the
mouth, on to the occlusal surfaces of the lower
teeth, with its long axis anteroposteriorly, and the
patient is asked to bite gently together.
 The X-ray tubehead is positioned in the midline,
centring through the chin point, at an angle of 45° to
the film

LOWER OBLIQUE OCCLUSAL
 This projection is
designed to allow the
image of the
submandibular salivary
gland, on the side of
interest, to be projected
on to the film.
However,because the
X-ray beam is oblique,
all the anatomical
tissues shown are
distorted.

MAIN INDICATIONS
 Detection of radiopaque calculi in a submandibular
salivary gland
 Assessment of the bucco-lingual position of
unerupted lower wisdom teeth
 • Evaluation of the extent and expansion of cysts,
tumours or osteodystrophies in the posterior part of
the body and angle of the mandible.

 The film packet, with the white (pebbly) surface facing
downwards, is inserted into the mouth, on to the
occlusal surfaces of the lower teeth, over to the side
under investigation, with its long axis anteroposteriorly.
The patient is asked to bite together gently.
 The patient's head is supported, then rotated away from
the side under investigation and the chin is raised. This
rotated positioning allows the subsequent positioning of
the X-ray tube head.
 The X-ray tubehead with circular collimator is aimed
upwards and forwards towards the film, from below and
behind the angle of the mandible and parallel to the
lingual surface of the mandible

PANORAMIC RADIOGRAPH
 Most Common
 It is a technique for producing a single tomographic
image of facial structures that includes both
maxillary and mandibular arches and their
supporting structures
 This is curvilinear variant of conventional
tomography and is also used on the principle of the
reciprocal movement of an x-ray source and an
image receptor around a central point or plane
called the image layer in which the object of interest
is located.

OPG
 Ortho - straight
 Panoramic - An obstructed or a complete view of
the object in every direction
 Tomography – An x-ray technique for making
radiographs of layers of tissue in depth, without the
interference of tissue above and below that level

MAIN INDICATIONS
Evaluation of-
 Trauma
 Location of third molars
 Extensive dental or osseous disease
 Known or suspected large lesions
 Tooth development
 Retained teeth or root tips
 TMJ pain
 Dental anomalies etc.

POSTERO-ANTERIOR OF THE JAWS (PA JAWS/PA
MANDIBLE)
the posterior parts of
the mandible. It is not
suitable for showing the
facial skeleton because
of superimposition of
the base of the skull
and the nasal bones.

MAIN INDICATIONS
 Fractures of the mandible involving the following sites:
Posterior third of the body
Angles
Rami
Low condylar necks
Lesions such as cysts or tumors in the
posterior third of the body or rami to note any
medio-lateral expansion
Mandibular hypoplasia or hyperplasia
 Maxillofacial deformities.

 The patient is in exactly the same position as for
the PA skull, i.e. the head tipped forward, the
radiographic baseline horizontal and perpendicular
to the film in the forehead-nose position.
 The X-ray tube head is again horizontal (0°), but
now the central ray is centered through the cervical
spine at the level of the rami of the mandible.

REVERSE TOWNE'S
the condylar heads and
necks. The original
Towne's view (an AP
projection) was designed
to show the occipital
region, but also showed
the condyles. However,
since all skull views used
in dentistry are taken
conventionally in the PA
direction, the reverse
Towne's (a PA
projection) is used.

MAIN INDICATIONS
 High fractures of the condylar necks
 Intra capsular fractures of the TMJ
 Investigation of the quality of the articular
 Surfaces of the condylar heads in TMJ disorders
 Condylar hypoplasia or hyperplasia.

 The patient is in the PA position, i.e. the head
tipped forwards in the forehead-nose position, but
in addition the mouth is open. The radiographic
baseline is horizontal and at right angles to the film.
Opening the mouth takes the condylar heads out of
the glenoid fossae so they can be seen.
 The X-ray tube head is aimed upwards from below
the occiput, with the central ray at 30° to the
horizontal, centered through the condyles.

LATERAL OBLIQUE
 The Film is positioned against the patient's cheek
overlying the ascending ramus and the posterior
aspect of the condyle of the mandible under
investigation.
 The Film is positioned so that its lower border is
parallel with the inferior border of the mandible but
lies at least 2 cm below it
 The mandible is extended as far as possible.
 The X-Ray tube is centered from the contralateral
side of the mandible at a point 2 cm below the
inferior border in the region of the first/second
permanent molar with angulation of 10 degrees
cephalad or caudal

RADIOLOGICAL INTERPRETATION OF FACIAL
TRAUMA
You see what you look for…!!!!

CAMPBELL’S AND TRAPNELL’S LINES
 Occipitomental
projection
 Fractures & other
signs are commonly
found.

CAMPBELL’S AND TRAPNELL’S LINES
 1st Line: Acrossthe zygomaticofrontal, the superior
margin of orbit and the frontal sinus.
 2nd Line: Across the zygomatic arch, zygomatic
body, inferior orbital margin and nasal bone.
 3rd Line: Across the condyles, coronoid and
maxillary sinus.
 4th Line: Across the mandibular ramus and the
occlusal Plane
 5th line: (Trapnell’s Line) Across the inferior border
of mandible and from angle to angle.

DOLAN & JACOBY’S LINE
(A) Orbital line.
It extends along the inner margins of the lateral,
inferior and medial walls of the orbit, passing over the
nasal arch to follow the same structures on the
opposite side
B) Zygomatic line.
It extends along the superior margin of the arch and
body of the zygoma, passing along the lateral margin of
the frontal process of zygoma to the zygomaticofrontal
suture

DOLAN & JACOBY’S LINE
 Maxillary Line
It extends along the
inferior margin of the
zygomatic arch, the
inferior margin of the
body and buttress of
the zygoma and the
lateral wall of the
maxillary sinus.

4 ‘S’ BY DELBALSO ET AL
 Symmetry.
 Sharpness – Bright sign, Trapdoor sign.
 Sinus.
 Soft tissues.
Swelling, foreign bodies, emphysema.

HOT SITES OF FRACTURE ON FACE
 Three fracture pattrens following lefort’s three line s of
weekness were recongnized i.e. Lefoet-1, Lefort-2 & Le-
fort-3.
 If these lines of weakness are mapped out onto the
image of an occipitomental 10 degree or modified
caldwell projection, than a pattren emerges and certain
sites provide likely hunting ground for recognizing injury
(hot sites).
 These are the areas where fractures are easily
manifested to the observer Particular attention should
therefore be paid to these areas.
 These lines of weakness are not precise and vary from
individual to individual. It doesn’t obeviate the need for a
complete study of the radiograph.

RADIOGRAPHIC SIGNS OF FRACTURE
Direct Signs
 Separation sign.
 Sutural diastasis.
 Overlap sign.
 Abnormal linear density
 Disappearing fragment
sign.
 Abnormal angulation.
 Step deformity
 Displaced Bone
 Widening of PDL Ligament

RADIOGRAPHIC SIGNS OF FRACTURE
Indirect signs
 Soft tissue swelling.
localized attention to that part
 Paranasal sinus opacification.
 Air in the soft tissues.
 Changes in occlusal plane

CHECKLIST
 Can be obtained to screen for facial injury if CT is
not Immediately available
 Multiple plain film projections are relative to
‘canthomeatal line’
 Proper positioning (of patient’s head), alignment of
xray beam is critical for evaluation because facial
skeletal anatomy is complex
 Remember: plain film is a 2D image of a 3D
object, Golden rule of Thumb is to Obtain two
radiographs at right angleto each other in order
to visualize a 3D object in a 2D radiograph

CHECKLIST
 Rule of symmetry: two sides of the face are quite
symmetrical, Symmetry is usual, and asymmetry
is suspect
 Multiplicity: fractures of facial bones are
frequently multiple.
 Do not stop looking for others when see one

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