Radiographic Positioning and Procedures 1

FINALS

SKULL
→ 22 separate bones
→ divided into two distinct groups:
→ 8 cranial bones and 14 facial bones

The cranial bones are further divided

• calvaria and floor
• Function: protective housing for the brain.

CRANIAL BONES (8)

Calvaria
1. frontal
• The bones of the cranium and face are
2. occipital
joined by fibrous joints called sutures.
3. right parietal
→ coronal, sagittal, squamosal, and
4. left parietal
lambdoidal

Floor
SUTURE
• ethmoid
CORONAL SUTURE
• sphenoid
→ found between the frontal and
• right temporal
parietal bones
• left temporal
SAGITTAL SUTURE
→ between the two parietal bones
SQUAMOSAL SUTURES
→ Between the temporal bones and
the parietal bones
LAMBDOIDAL SUTURE
→ Between the occipital bone and the
parietal bones

FONTANELLES
Bregma
→ The junction of the coronal and
sagittal sutures
Lambda
→ the junction of the lambdoidal and
sagittal sutures
Pterion
→ the junction of the parietal bone,
squamosal suture, and greater wing
of the sphenoid
Asterion
→ junction of the occipital bone,
parietal bone, and mastoid CRANIAL BONES

Frontal bone

→ Frontal bone has a vertical portion

and horizontal portions
Vertical portion
→ called the frontal squama
→ forms the forehead and the anterior
part of the vault
Horizontal portions
→ called the orbital plates (roofs of the
SIX AREA OF INCOMPLETE OSSIFICATION orbit)
→ part of the roof of the nasal cavity,
Anterior fontanel (1) and the greater part of the anterior
cranial fossa
→ the junction of the two parietal
bones and the one frontal bone at Frontal eminence
the bregma → Rounded elevation of the frontal
bone
Posterior fontanel (1)
superciliary arches
→ located at the point labeled lambda → Below the frontal eminences, just
Sphenoidal fontanel (2) above the supraorbital margins, are
two arched ridges that correspond
→ found at the site of the pterion in position to the eyebrows
Mastoid fontanels (2) superciliary arches
→ Found at the asteria. supraorbital foramen
→ In the center of the supraorbital
margin is an opening for nerves and
● The cranium develops
blood vessel called the supraorbital
→ first 5 or 6 years
foramen
→ And stop at the age of 12 years old
 horizontal portion
→ called the cribriform plate

Glabella

vertical portion
→ is called the perpendicular plate

→ The smooth elevation between the

superciliary arches

nasion
→ The midpoint of the frontonasal
suture

ethmoidal notch
→ Separate orbital plates of the
horizontal portion of the frontal bone

Frontal bone articulation

● the right and left parietals,
● sphenoid,
● ethmoid bones of the cranium.

ETHMOID BONE

→ Ethmoid bone is a small, cube-

shaped bone
→ consists of a horizontal plate, a
vertical plate,
labyrinths
→ two light, spongy lateral
→ labyrinths contain the ethmoidal
sinuses, or air cells.
o anterior; middle, and posterior
ethmoidal air cells
→ superior and middle nasal conchae

o two thin, scroll-shaped of the

labyrinths

Crista galli
→ The plate also has a thick, conical
Parietal bone articulations
process
● frontal, temporal, occipital,
→ Function: serves as the anterior
sphenoid, and opposite parietal
attachment for the falx cerebri
bone of the cranium.

SHPENOID BONE

→ irregularly wedge-shaped bone that

somewhat resembles a bat with its
wings extended.
→ situated in the base of the cranium
anterior to the temporal bones and
basilar part of the occipital bone
sphenoid
→ two lesser wings and two greater
wings
→ and two pterygoid processes, which
Ethmoid bone articulation project inferiorly from each side of
● Frontal bone the inferior surface of the body.
● sphenoid bones

PARIETAL BONES

→ two parietal bones

o convex external surface and a
concave internal surface

parietal eminence

→ prominent bulge
 greater wings
→ curve laterally, posteriorly, anteriorly,
and superiorly
→ The foramina rotundum, ovale, and
spinosum
o Function: transmit nerves and
blood vessels,
→ body of the sphenoid bone contains pterygoid processes
the two sphenoidal sinuses, which → arise from the lateral portions of the
are incompletely separated by a inferior surface
median septum. → Medial portions of the inferior
sella turcica surfaces of the greater wings.
→ Superior surface of the sphenoid bone
present deep depression sphenoid bone articulation
→ Contain pituitary gland
→ Location: ¾ inch anterior and ¾ inch → seven bones of the cranium
superior to EAM
ОССРІТAL BONE
Sella Turcica is bounded
→ anteriorly by the tuberculum sellae
→ situated at the posteroinferior part
→ posteriorly by the dorsum sellae
of the cranium.
o which bear the posterior
→ The occipital bone has four parts:
clinoid processes
• squama, which is saucer-shaped
Clivus
convex externally
→ slanted area of bone posterior and
• two occipital condyles which
inferior to the dorsum sellae is
extend anteriorly, one on each
continuous with the basilar portion of
side of the foramen magnum
the occipital bone
• basilar portion.
lesser wings
→ Triangular in shape and nearly foramen magnum
horizontal in position. ● which the inferior portion of the
→ form the posteromedial portion of medulla oblongata passes as it exits
the roofs of the orbits the cranial cavity and joins the spinal
→ Forms upper margin of the superior cord
orbital fissures inion
→ medial ends of their posterior borders ● External occipital protuberance or
form the anterior clinoid processes inion.
Each process arises from two roots jugular foramen
→ Anterior (superior) root is thin and flat → important large opening in the skull
→ posterior (inferior) root, referred to as for two reasons
the sphenoid strut, is thick and → it allows blood to drain from the
rounded brain via the internal jugular vein,
 and it lets three cranial nerves pass → is the thin, upper portion of the
through it. temporal bone
Occipital bone articulation Zygomatic process
→ two parietals, → projects anteriorly to articulate with
→ two temporals the zygomatic bone of the face and
→ sphenoid of the cranium thus complete the zygomatic arch.
→ Cl
→ The mandibular fossa receives the
condyle of the mandible to form
the temporomandibular joint
(TMJ).

The EAM
→ ½ inch (1.3 cm) in length
→ projects medially, anteriorly, and
slightly superiorly.
styloid process
→ slender, pointed bone of variable
length,
→ projects inferiorly, anteriorly, and
slightly medially from the inferior
portion of the tympanic part of the
temporal bone.

Petromastoid Portion

→ petrous and mastoid portions

mastoid portion articulates
→ parietal bone at its superior border
→ Occipital bone at its posterior border
through the occipitomastoid suture

→ The mastoid process varies

considerably in size, depending
on its pneumatization, and is
TEMPORAL BONES
larger in males than in females.
→ irregular in shape and are situated
mastoid antrum
on each side of the base of the
cranium between the greater wings
of the sphenoid bone and the
occipital bone
squamous portion
 → first of the mastoid air cells to
develop is situated at the upper
anterior part of the process and is
termed the mastoid antrum.

Petrous portion/ Petrous pyramid/ Parse

Petrosa / Petrous Ridge
→ conical or pyramidal and is the
thickest, densest bone in the
cranium.
→ Contain organ of hearing and
balance.
→ Form base at the squamous and
FACIAL BONES
mastoid portions

→ top of the ridge lies approximately at

the level of an external radiography
landmark called the top of ear
attachment (TEA).

internal acoustic meatus (IAM)

→ center of the posterior aspect of the
petrous portion

temporal bone articulation

→ parietal,
→ occipital,
→ Sphenoid

(NaLaMaZ IVM)

NASAL BONES
→ They articulate with the frontal bone
above and with the maxillae at the
sides.
LACRIMAL BONES
→ smallest bones in the skull
→ can be seen on PA and lateral
projection of the skull
MAXILLARY BONES
→ largest of the immovable bones of
the face
 → articulates with all other facial bones • TMJ, slants posteriorly approximately 15
except the mandible degrees and inferiorly and medially
→ The midpoint of this prominence is approximately 15 degrees
called the acanthion/ anterior nasal
spine
ZYGOMATIC BONES
→ Prominence of the cheeks
→ articulate with the frontal bone
superiorly
PALATINE BONES
→ L-shaped bones
→ composed of vertical and horizontal
plates
→ horizontal plates articulate with the
maxillae
→ vertical portions extend upward
between the maxillae and the HYOID BONE
pterygoid processes
INFERIOR NASAL CONCHAE → small, U-shaped structure
→ inferior nasal conchae extend → situated at the base of the tongue
diagonally and inferiorly from the → only bone of the body that does not
lateral walls of the nasal cavity articulate directly with any other
VOMER bone
→ thin plate of bone situated in the → Two body:
midsagittal plane of the floor of the → two greater cornua, and two lesser
nasal cavity cornua
→ Forms nasal septum
MANDIBLE ORBITS
→ largest and densest bone of the
→ seven different bones (FES PaLaMaZ)
face
→ Cranial bones
→ Horizontal portion, called the Body
o frontal, sphenoid, and
→ Two vertical portions, called the rami
ethmoid.
mental foramina → Facial bone
o maxilla, zygoma, lacrimal,
→ a small opening on each side for and palatine
the transmission of nerves and blood → circumference of the orbit, or outer
vessels. These two openings are rim are frontal, zygoma, and maxilla
called the mental foramina.
 JOINTS OF THE SKULL

• Infraorbitomeatal line (IOML0

• Acanthiomeatal line (AML)
• Mentomeatal Iine (MML)

● OML - IOML = 7 degree difference

SUMMARY OF PATHOLOGY
● GML to OML = 8 degree difference
● GML to IOML = 15 degree difference
● IOML to AML = 8 degree difference

• Note: may vary, depending on the

cranial line of reference

Skull Morphology

Mesocephalic skull
→ Typical skull morphology
Skull Topography → The petrous pyramids lie at an
average angle of 47 degrees to MSP
→ Accurate positioning of the skull
requires a full understanding of Brachycephalic skull
these landmarks, which should be → short from front to back, broad from
studied thoroughly before side to side
positioning of the skull is Learned. → shallow from vertex to base
• Midsagittal plane → The petrous pyramids lie at an
• Interpupillary line average angle of 54 degrees to MSP
• Acanthion
• Outer canthus Dolichocephalic skull
• Infraorbital margin → Long from front to back, narrow from
• External acoustic meatus (EAM) side to side
• Orbitomeatal line (OML) → deep from vertex to base
 → The petrous pyramids lie at an 8. Mastoiditis
average angle of 40 degrees to MSP → Inflammation of mastoid
antrum & air cells
SKULL PLANES, POINTS & LINE
9. Paget's Disease
• Midsagittal plane (MSP)
→ Thick, soft bone marked by
• Interpupillary line (IPL)
bowing fxs
• Acanthion
• Outer canthus
• Infraorbital margin 10. Sinusitis
• External acoustic meatus (EAM) → Inflammation of one or more of
• Orbitalmeatal line (OML) the paranasal sinuses
• Infraorbitomeatal line
(TOML)/Frankpurt Line 11. TMJ Syndrome
• Acanthiomeatal line (AML) → Dysfunction of the
• Mentomeatal line (MML) temporomandibular joint
• Between OML & 1OML: 7° difference 12. Tumor
• Between OML & GML: 8° difference → New tissue growth where
cell proliferation is
uncontrolled
Pathology • Acoustic Neuroma
1. Basal Fx → Benign tumor arising from
→ Fx located at the base of the skull Schwann cells of the eighth
2. Blowout Fx
cranial nerve
→ Fx of the floor of the orbit
• Multiple Myeloma
3. Contre-Coup Fx
→ Malignant neoplasm of
→ Fx to one side of a structure
plasma cells involving the
caused by trauma to the other
side bone marrow and causing
4. Depressed Fx destruction of the bone
→ Fx causing a portion of the skull to • Osteoma
be depressed into the → Tumor composed of bony
cranial cavity tissue
5. Le Fort Fx • Pituitary Adenoma
→ Bilateral horizontal fxs of the → Tumor arising from the
maxillae pituitary gland, usually in the
6. Linear Fx anterior lobe
→ Irregular or jagged fx of the skull
7. Tripod Fx
→ Fx of the zygomatic arch & SKULL PROJECTIONS
orbital floor/rim & dislocation CRANIUM
of the frontozygomatic suture PA PROJECTION
PP: Prone; forehead & nose against IR; MSP • Petrous pyramid to lower 1/3 of orbit
& OML perpendicular to IR • Superior orbital fissure/sphenoid
RP: Nasion fissure (20-25° caudad) & foramen
CR: Perpendicular rotundum (25-30° caudad)
SS: Petrous pyramid completely filled the
orbits; frontal bone

AP PROJECTION
PP: Supine; MSP & OML perpendicular to IR
RP: Nasion
CR: Perpendicular
SS: Same as PA, but the image is
MAGNIFIED

MODIFIED CALDWELL METHOD

PA AXIAL PROJECTION
PP: Prone; forehead & nose against IR; OML
perpendicular to IR, MSP perpendicular to AP AXIAL PROJECTION
IR PP: Supine; OML perpendicular to IR
RP: Nasion RP: Nasion
CR: 15° caudad CR: 15° cephalad
SS: SS: Same as PA axial but orbits are
General Survey Examination: magnified & the distance b/n lateral
• Anterior & side walls of the cranium margin of orbits & temporal bones are less
• Temporal fossae on AP than PA
• Frontal sinuses & anterior ethmoid
sinus
• Crista galli
• Upper 2/3 of orbits
 TRUE/ORIGINAL CALDWELL TOWNE/ ALTSCHUL/
PP: Prone; forehead & nose against IR; GML GRASHEY/CHAMBERLAINE
perpendicular to IR; MSP perpendicular to METHOD
IR • AP AXIAL PROJECTION
RP: Nasion PP: Supine; OML/IOML & MSP perpendicular
CR: 23° caudad to IR;
SS: Same as above RP: 2.5-3 in. above glabella
CR: 30° caudad (OML); 37° caudad (IOML)
LATERAL PROJECTION ER: For patient w/ pathologic condition,
PP: Semi-prone, MSP & IOML parallel to IR; trauma or deformity (strongly accentuated
IPL perpendicular to IR dorsal kyphosis)
RP: 2 in. Above EAM or midway b/n inion & SS:
glabella
CR: Perpendicular • "SPDOP" TEP
SS: SADSME • Symmetric petrous pyramid
General survey examination: • Posterior portion of foramen
• Sella turcica magnum
• Anterior & posterior clinoid • Dorsum sellae & posterior clinoid
processes, process w/in shadow of foramen
• Dorsum sellae magnum
• Superimposed mandibular rami • Occipital bone
• Mastoid region • Posterior portion of parietal bone
• EAM & TMJ • Tomographic studies of ears, facial
canal, jugular foramina & rotundum
foramina
• Entire foramen magnum & jugular
foramina (40-60° caudad to OML)
• Posterior portion of cranial vault (CR
⊥ to midway b/n frontal tuberosities)

CROSSTABLE LATERAL
PP: Dorsal decubitus (Robinson, Meares &
Goree recommendation);
MSP perpendicular to IR
RP: 2 in. Above EAM
CR: Horizontal
ER: For traumatic sphenoid sinus effusion
(basal skull fx) N
 HAAS METHOD SS: Cranial base
PA AXIAL PROJECTION • Foramen ovale & spinosum (best
PP: Prone; MSP & OML perpendicular to IR; demonstrated)
forehead & nose against the table; IR • Symmetric petrosae
center 1 in. to nasion • Mastoid processes
RP: 1.5 in. below inion (entrance); 1.5 in. • Carotid canals
superior to nasion (exit) • Sphenoidal & ethmoidal sinuses
CR: 25° cephalad to OML
• Mandible
SS:
• Bony nasal septum
• Occipital bone
• Dens of axis
• Symmetric petrous pyramid
• Occipital bone
• Dorsum sellae & posterior clinoid
processes w/in shadow of foramen • Maxillary sinus superimposed over
magnum the mandible
ER: For obtaining image of sellar structures • Zygomatic arches (well
(DS & PCP) w/in FM on hypersthenic & demonstrated if exposure factors are
obese patient decreased)
• Axial tomography of orbits, optic
canals, ethmoid bone, maxillary
sinuses & mastoid processes

SCHULLER/PEEIFFER METHOD
• SUBMENTOVERTICAL PROJECTION
PP: Supine or Seated-upright (more
comfortable); IOML parallel to IR; MSP
perpendicular to IR; head rested on vertex;
neck hyperextended
RP: ¾ in. anterior to EAM (sella turcica)
CR: Perpendicular to IOML; MSP of throat
b/n gonion (entrance)
 SCHULLER METHOD LYSHOLM METHOD
VERTICOSUBMENTAL PROJECTION AXIOLATERAL METHOD
PP: Prone; chin fully hyperextended; MSP PP: Semiprone; MSP parallel to IR;
perpendicular to IR IOML parallel to transverse axis of IR, IPL
RP: ¾ in. anterior to EAM (sella turcica) perpendicular to IR
CR: Perpendicular to IOML; MSP of throat RP: 1 in. distal to lower EAM (exit)
b/n gonion (entrance) CR: 30-35° caudad
SS: Same as SMV SS: Oblique position of lateral aspect of
• Distorted & magnified basal cranial base closest to IR
structures ER: For patients who cannot extend their
• Useful for anterior cranial base & head enough for a satisfactory SMV
sphenoidal sinuses projection
• IR in contact with the throat
• Reduces magnification & distortion

VALDINI METHOD
PA AXIAL PROJECTION
• 50/50
PP: Recumbent or seated-erect (more
comfortable); upper frontal region of skull
against IR; MSP perpendicular to IR; head
acutely flexed; IOMI 50°/OML 50°; line
extending from inion to 0.5 cm distal to
nasion form 28° to CR

RP: 0.5 cm distal to nasion (dorsum sellae);

foramen magnum/slightly above level of
EAM (petrosae)

CR: Perpendicular, inion (entrance); 0.5 cm

Note:
distal to nasion (exit)
Baseline
SS:
PA/ AP → OML ⊥
• DILA (IOML 50°): Dorsum sellae; Internal
Lateral → IOML ∥ Auditory Meatus (IAM);
LAbyrinth
 • Dorsum sellae & posterior clinoid
processes w/in shadow of foramen
magnum (37° caudad)
• Symmetric petrous pyramid

• ETB "EaT Bulaga" (OML 50º): External

HAAS METHOD
auditory meatus;
PA AXIAL PROJECTION
Tymphanic cavity; Bony part of Eustachian
PP: Prone; MSP & OML perpendicular to IR;
tube
forehead & nose against the table; IR
center 1 in. to nasion
• Dorsum sellae & posterior clinoid
RP: 1.5 in. below inion (entrance); 1.5 in.
processes within or above shadow of
superior to nasion (exit)
foramen magnum
CR: 25° cephalad to OML
SS:
• Tuberculum sellae, anterior clinoid
• Dorsum sellae & posterior clinoid
processes & sella turcica below shadow of
processes win shadow of foramen magnum
foramen magnum
• Symmetric petrous pyramid
• ER: For obtaining image of sellar structures
• Mastoid pneumatization
(DS & PCP) w/in FM on hypersthenic &
obese patients

SELLA TURCICA
PA PROJECTION
LATERAL PROJECTION
PP: Prone; forehead & nose against IR; MSP
PP: Semiprone; MSP & IOML parallel to IR;
& OML perpendicular to IR
IPL perpendicular to IR
RP: Glabella
RP: ¾ in. anterior & ¾ in. superior to EAM
CR: 10° cephalad
CR: Perpendicular
SS: Dorsum sellae, tuberculum sellae,
SS: Superimposed anterior & posterior
anterior & posterior clinoid processes
clinoid processes; dorsum sellae
through frontal bone above ethmoidal
sinuses
TOWNE METHOD
PP: Supine; OML/IOML & MSP perpendicular
to IR;
OPTIC CANAL/ FORAMEN
RP: 2.5-3 in. above glabella
RHESE METHOD
CR: 30° caudad (OML ⊥), 37° caudad
• PARIETO-ORBITAL OBLIQUE PROJECTION
(IOML ⊥)
PP: Prone; affected orbit closest to IR;
SS: Sellar region
zygoma, nose & chin against IR (3-pt
• Dorsum sellae, tuberculum sellae &
Lower Landing); AML perpendicular to IR;
anterior clinoid processes through occipital
MSP 53° angle to IR
bone above shadow of foramen magnum
RP: Affected orbit closest to IR
(30° caudad)
CR: Perpendicular
SS: Optic canal/foramen (inferior & lateral SPHENOID STRUT
quadrant of orbital shadow) HOUGH METHOD
• PAZAM: Prone; Affected orbit against IR; • PARIETO-ORBITAL OBLIQUE PROJECTION
Zynoch; AML -; MSP 53° to IR 20/20
PP: Prone; superciliary ridge/arch & side of
the nose against IR; IOML perpendicular to
IR; MSP 20° from vertical; MSP 20° toward
the side of interest
RP: Affected orbit (exit)
CR: 7° caudad
SS: Unobstructed & undistorted image of
the sphenoid strut (lie b/n sphenoidal sinus
& combined shadows of anterior clinoid
processes & lesser wing of sphenoid bone)
ALEXANDER METHOD
• ORBITO-PARIETAL OBLIQUE PROJECTION SUPERIOR ORBITAL FISSURE
PP: Erect/supine; IR 15° angle from vertical; CALDWELL METHOD
MSP 40° to IR; AML perpendicular to IR • PA AXIAL PROJECTION
RP: Inferior and lateral margin of uppermost PP: Prone; forehead & nose against IR; OML
orbit perpendicular to IR
CR: Perpendicular RP: Nasion
SS: Optic canal/foramen CR: 20-25° caudad or 15° caudad
SS: Superior orbital fissures
• Lying on the medial side of orbits b/n
greater & lesser wings of sphenoid)
• Well demonstrated at 15° caudal angle
(Caldwell)
• Petrous portions at or below the inferior
orbital margin

MODIFIED LYSHOLM METHOD

• ECCENTRIC ANGLE PARIETO-ORBITAL
OBLIQUE PROJECTION
PP: Prone; forehead & nose against IR; IOML
perpendicular to IR; MSP 20° from vertical;
RP: Affected orbit (exit)
CR: 20° caudad or 30° caudad INFERIOIR ORBITAL FISSURE
SS: Optic canal/foramen & anterior clinoid BERTEL METHOD
processes (20°); superior orbital fissure (30°) • PA AXIAL PROJECTION
PP: Prone; forehead & nose against IR; IOML
perpendicular to IR
RP: Nasion SS: Petrous pyramids lying well below orbital
CR: 20-25° cephalad shadows
SS: Inferior orbital fissures
• b/n shadows of pterygoid process of
sphenoid bone & mandibular ramus
• Anterior image of each orbital floor

VOGT-BONE-FREE POSITION
• Taken to detect small or low-density
foreign particles located in the anterior
segment of the eyeball/eyelids
• 2 Projections: lateral & superoinferior
• 2 Movements:
EYE FOREIGN BODY LOCALIZATION • Vertical: 2 exposures (for lateral)
LATERAL PROJECTION • Look up as far as possible
PP: Semiprone; MSP parallel to IR; IPL • Look down as far as possible
perpendicular to IR; instruct patient to look • Horizontal: 2 exposures (for superoinferior)
straight ahead during exposure • Look to extreme right
RP: Outer canthus • Look to extreme left
CR: Perpendicular
SS: Superimposed orbital roofs PARALLAX METHOD

PA AXIAL PROJECTION • First described by Richards

PP: Prone; forehead & nose against IR; MSP • It determines whether the foreign body is
& OML perpendicular to IR; instruct patient located within the eyeball requires no
to close the eyes special apparatus
RP: Midorbits • Not considered as precision localization
CR: 30° caudad procedure
SS: Petrous pyramids lying below orbital • Widely used as preliminary check only
shadows • 2 Projections:
• Lateral: 2 exposures
MODIFIED WATERS METHOD • PA: 2 exposures
• PARIETOACANTHIAL PROJECTION
PP: Prone; chin against IR; MSP SWEET METHOD
perpendicular to IR; OML 50° to IR (new); • It determines the exact location of a
OML 25-37° to IR (old); instruct patient to foreign body by use of a geometric
close the eyes calculations
RP: Midorbits • Apparatus:
CR: Perpendicular o Sweet localizing device
• Sweet film pedestal
• 1 Projection: MODIFIED WATERS
• Lateral: 2 exposures PP: Prone; MSP & MML perpendicular to IR;
* CR perpendicular OML 55° to IR
• CR 15-25° cephalad RP: Acanthion (exit)
CR: Perpendicular
PFEIFFER-COMBERG METHOD SS: Facial bones w/ less axial angulation
• A leaded contact lens is placed directly • Petrous ridges below the inferior border of
over the cornea orbits
• Apparatus:
• Contact lens localization device REVERSE WATERS METHOD
• Pedestal type of film holder • AP AXIAL PROJECTION
• 2 Projections: PP: Supine; MSP & MML perpendicular to IR;
• Waters Method: OML 37° to IR; chin up
• CR horizontal RP: Acanthion (exit)
• Lateral: CR: Perpendicular
• CR perpendicular SS: Superior facial bones; same as
True/Original Waters, but the image is
MAGNIFIED
FACIAL BONE ER: For patient who cannot be placed in
LATERAL PROJECTION the prone position
PP: Semiprone; MSP & IOML parallel to IR;
IPL perpendicular to IR
RP: Zygoma/malar bone
CR: Perpendicular
SS: Superimposed facial bones
• Superimposed mandibular rami & orbital
roofs

WATERS METHOD
• PARIETO-ACANTHIAL PROJECTION
PP: Prone; MSP & MML perpendicular to IR; CALDWELL METHOD
OML 37° to IR; nose ¾ in. (1.9 cm) away • PA AXIAL PROJECTION
from IR PP: Prone; forehead & nose against IR; OML
RP: Acanthion (exit) perpendicular to IR
CR: Perpendicular RP: Nasion
SS: Orbits, maxillae & zygomatic arches CR: 15° caudad or 30° caudad
PBB (Exaggerated Caldwell)
• Best projection for facial bones SS: Orbital rims, maxillae, nasal septum,
• Petrous ridges below the maxillae zygomatic bones & anterior nasal spine
• Blow out fractures • Petrous ridges at lower third of orbits (15°
caudad)
• Petrous ridges below the inferior orbital CR: Perpendicular
margins (30° caudad) SS: Nasal bones with minimal
• Orbital floors (30° caudad) superimposition
ER: For demonstration of any medial or
LAW METHOD lateral displacement of fragments in
•PA OBLIQUE AXIAL PROJECTION fractures
PP: Semiprone; zygoma, nose & chin Contraindications:
against IR; unaffected side against IR; OML • Children or adults who have very
perpendicular to IR, short nasal bones, concave face or
Center IR 2 in above floor of maxillary protruding upper teeth
sinuses
RP: Lower antrum
CR: 25-30° cephalad; posterior to gonion
(entrance)
SS: FEZA
• Floor & posterior wall of maxillary sinus WATERS METHOD
(antrum) of side down • PARIETO-ACANTHIAL PROJECTION
• External orbital wall PP: Prone; MSP & MML perpendicular to IR;
• Zygomatic bone OML 37° to IR; nose ¾ in. (1.9 cm) away
• Anterior wall of maxillary sinus of side up from IR
RP: Acanthion (exit)
NASAL BONE CR: Perpendicular
LATERAL PROJECTION ER: Displacement of bony nasal septum &
PP: Semiprone; MSP & IOML parallel to IR; depressed fx of nasal wings
IPL perpendicular to IR
RP: ¾ in. (old) or ½ in. (new) distal to nasion ZYGOMATIC ARCHES
CR: Perpendicular • SUBMENTOVERTICAL PROJECTION
SS: Nasal bones of side down & soft tissue PP: Supine or Seated-upright (more
structures comfortable); IOML parallel to IR; MSP
perpendicular to IR; head rested on vertex;
TANGENTIAL PROJECTION neck hyperextended
PP: RP: midsagittal plane of the throat at
•Extraoral Film (Cassette): prone; chin a level approximately I inch (2.5 cm)
rested on sandbags, chin fully posterior to the outer canthi)
extended; MSP & GAL perpendicular CR: Perpendicular to IOML; MSP of throat
to IR b/n gonion (entrance)
• Intraoral Film (Occlusal Film): supine; SS: zygomatic arch free from superimposed
head elevated; MSP perpendicular structures
to sponge; GAL parallel to sponge &
perpendicular to film MODIFIED TITTERINGTON METHOD
RP: Glabelloalveolar line • PA AXIAL (SUPEROINFIOR) PROJECTION
PP: Prone; nose & chin against IR; MSP ER: To demonstrate any medial or lateral
perpendicular to IR displacement of fragments in fractures of
RP: Vertex midway b/n zygomatic arches the rami
CR: 23-38° caudad
SS: Well shown zygomatic arches PA AXIAL PROJECTION
PP: Prone; forehead & nose against IR; OML
MAY METHOD & MSP perpendicular to IR
• TANGENTIAL PROJECTION RP: Acanthion (exit)
PP: Prone/seated; neck fully extended; CR: 20 or 25° cephalad
IOML parallel to IR; MSP rotated 15° SS: Condylar processes; mandibular rami
toward the side of interest; head tilted 15° ER: To demonstrate any medial or lateral
RP: Zygomatic arch at 1.5 in. posterior to displacement of fragments in fractures of
outer canthus the rami
CR: Perpendicular to IOML
SS: Zygomatic arch free of superimposition
ER: Useful with patients who have PA PROJECTION
depressed fractures or flat cheekbones PP: Prone; nose & chin against IR; AML &
MSP perpendicular to IR
RP: Level of lips
CR: Perpendicular
SS: Mandibular body

PA AXIAL PROJECTION
PP: Prone; nose & chin against IR; AML &
MODIFIED TOWNE METHOD MSP perpendicular to IR; fill the mouth with
• AP AXIAL PROJECTION air to obtained better contrast around TMJs
• JUG HANDLE VIEW (Zanelli recommendation)
PP: Supine; OML/OML & MSP perpendicular RP: Midway b/n TMJs
to IR; CR: 30° cephalad
RP: Glabella (1 in. above nasion) SS: Mandibular body; TMJs; condylar
CR: 30° caudad (OML ); 37° caudad (IOML) processes
SS: Bilateral symmetric zygomatic arches
free of superimposition AXIOLATERAL OBLIQUE PROJECTION
PP: Seated/semiprone/semisupine; head in
MANDIBLE true lateral & IPL perpendicular to IR
PA PROJECTION (ramus); head rotated 30° toward IR
PP: Prone; forehead & nose against IR; OML (body); head rotated 45° toward IR
& MSP perpendicular to IR (symphysis); head rotated 10-15° toward IR
RP: Acanthion (exit) (general survey),
CR: Perpendicular mouth closed; neck extended (prevent
SS: Mandibular rami superimposition of cervical spine) -
 • Provides distortion-free lateral image of
RP: Mandibular region of interest the entire mandible
CR: 25° cephalad • Patients who sustained severe mandibular
SS: Mandibular body & TMJs or TMJ trauma
ER: To place the desired portion of the • Useful for general survey studies of dental
mandible parallel with the IR abnormalities
• Muscular/Hypersthenic Patients: MSP • Adjuvant for pre-bone marrow transplant
15° & CR 10° cephalad
• To reduce the possibility of TMJ
projecting shoulder over the TOWNE METHOD
mandible • AP AXIAL PROJECTION
PP: Supine; MSP & OML perpendicular to IR
SCHULLER/PFEIFFER METHOD • Closed-mouth Position: posterior teeth in
• SUBMENTOVERTICAL PROJECTION contact not incisors
PP: Supine or Seated-upright (more • Rationale: prevents mandibular
comfortable); IOML parallel to IR; MSP protrusion & condyles to be carried out
perpendicular to IR; head rested on vertex; of mandibular fossae
neck hyperextended • Opened-mouth Position: open as wide as
RP: Midway b/n gonions possible
CR: Perpendicular to IOML • Mandible not protruded (jutted forward)
SS: Mandibular body; coronoid & condyloid • Not perform in trauma patients
processes of rami RP: 3 in. above nasion
CR: 35° caudad
SCHULLER METHOD SS: Mandibular condyles & mandibular
VERTICOSUBMENTAL PROJECTION fossae of temporal bones
PP: Prone; chin fully hyperextended; IR • Closed-mouth: condyle lying in
against throat; MSP perpendicular to IR mandibular fossa
RP: Level just posterior to outer canthi • Opened-mouth: condyles lying inferior
CR: Perpendicular to IOML or occlusal to articular tubercle
plane
SS: Condyle & neck of condylar processes AXIOLATERAL PROJECTION
are better shown PP: Semiprone; head in lateral position; IPL
(CR + occlusal plane) perpendicular to IR; MSP parallel to IR;
closed-mouth & opened-mouth position
PANORAMIC TOMOGRAHY/ RP: 0.5 in. anterior & 2 in. superior to upside
PANTOMOGRAPHY/ROTATIONAL EAM
TOMOGRAPHY CR: 25-30° caudad
• -technique employed to produced SS: TMJ anterior to EAM
tomograms of curved surfaces- • Closed-mouth: condyle lying in
• Provides panoramic image of the entire mandibular fossa
mandible, TMJ, dental arches
 • Opened-mouth: condyles lying inferior SS: TMJ
to articular tubercle
SINUSES
SCHULLER METHOD Cross & Flecker: pointed out the value of
• AXIOLATERAL OBLIQUE/LATERAL erect position
TRANSCRANIAL/AXIAL TRANSCRANIAL • To demonstrate presence or absence of
PROJECTION fluid
PP: Semiprone; MSP rotated 15° toward the • To differentiate between shadows
IR; AML parallel to transverse axis of IR; caused by fluid & those caused by
RP: 1.5 in. superior to upside EAM pathology
CR: 15° caudad; TMJ of sidedown (exit) LATERAL-skipped
SS: Condyles & neck of the mandible Basta all paranasal and naka upright
• Closed-mouth: fracture of the neck & RP: 1/2 - I inch posterior to the outer
condyle of ramus canthus
• Opened-mouth: mandibular fossa; PA PROJECTION
inferior & anterior excursion of the PP: Upright; forehead & nose against IR;
condyle MSP & OML perpendicular to IR
RP: Nasion (⊥); glabella (10° cephalad);
INFEROSUPERIOR TRANSFACIAL POSITION midregion of maxillary sinuses
PP: Semiprone; head in true lateral; IPL 10- CR: Perpendicular, 10° cephalad;
15° from perpendicular; MSP 15° from IR perpendicular
RP: Uppermost gonion SS:
CR: 30° cephalad • Posterior ethmoid sinuses inferior to
SS: TMJ cranial bones & superior to anterior
ethmoid sinuses (⊥)
ALBERS-SCHONBERG METHOD • Sphenoidal sinuses through frontal bone
• LATERAL TRANSFACIAL POSITION & superior to frontal & ethmoid sinuses
PP: Semiprone; head in true lateral; IPL • Maxillary sinuses inferior to cranial base
perpendicular to IR; MSP parallel to IR; IOML CALDWELL METHOD
parallel to transverse axis of IR • PA AXIAL PROJECTION
RP: TMJ closes to IR (exit) PP: Upright
CR: 20° cephalad • Angle grid technique: nose & forehead
SS: TMJ against IR; IR tilted 15°; MSP & OML
perpendicular to IR
ZANELLI METHOD • Vertical grip technique: nose against IR;
• LATERAL TRANSFACIAL POSITION OML 15° from IR; sponge b/n forehead & IR;
PP: Lateral recumbent; head in true lateral; MSP perpendicular to IR
head resting on parietal region; MSP 30° to RP: Nasion
IR CR: Horizontal
RP: Uppermost gonion (entrance) SS: Frontal sinuses & anterior ethmoidal
CR: Perpendicular sinuses
 WATERS METHOD CR: Perpendicular to IOML; MSP of throat
• PARIETOACANTHIAL PROJECTION b/n gonion (entrance)
PP: Upright, neck hyperextended & rested SS: Sphenoidal sinuses
against IR, OML 37° to IR; MML • Posterior ethmoidal sinuses
perpendicular to IR • Maxillary sinuses
RP: Acanthion • Nasal fossae
CR: Horizontal
SS: Maxillary sinuses
• Petrous pyramids inferior to floor of PIRIE METHOD
maxillary sinus AXIAL TRANSORAL POSITION
• Foramen rotundum PP: Upright (prone; nose & chin against IR;
• Distorted frontal & ethmoidal sinuses mouth wide open; MSP perpendicular to IR;
OPEN-MOUTH WATERS METHOD phonate "ah" during exposure
• PARIETOACANTHIAL PROJECTION RP: ¾ in. anterior to EAM (sella turcica)
PP: Upright; neck hyperextended & rested CR: Perpendicular
against IR; OMI 37° to IR; MML SS: Sphenoidal sinuses projected through
perpendicular to IR; mouth wide open open mouth
RP: Acanthion • Maxillary sinuses
CR: Horizontal • Nasal fossae
SS: Sphenoidal sinuses projected through
open mouth RHESE METHOD
• Petrous pyramids inferior to floor of • PA OBLIQUE POSITION
maxillary sinus PP: Seated-erect; zygoma, nose & chin
ER: For the patients who cannot be placed against IR; AML perpendicular to IR; MSP 53°
in position for SMV from IR
SCHULLER METHOD RP: Upper parietal region
• SUBMENTOVERTICAL PROJECTION CR: Perpendicular
PP: Upright; IOML parallel to IR; MSP SS: Oblique image of posterior & anterior
perpendicular to IR; head rested on vertex; ethmoidal sinuses
neck hyperextended • Frontal & sphenoidal sinuses
RP: ¾ in. anterior to EAM (sella turcica) • Profile image of the optic canal
CR: Perpendicular to IOML; MSP of throat
b/n gonion (entrance) LAW METHOD
SS: Sphenoidal & ethmoidal sinuses • PA OBLIQUE POSITION
• Anterior portion of the base of the skull PP: Seated-erect; zygoma, nose & chin
SCHULLER METHOD against IR; neck fully extended
• VERTICOSUBMENTAL PROJECTION RP: Uppermost gonion
PP: Seated-erect; chin fully hyperextended; CR: 25-30° cephalad
MSP perpendicular to IR SS: Relationship of teeth to maxillary sinuses
RP: ¾ in. anterior to EAM (sella turcica)
 MASTOID Petrosae above base of the skull
LAW METHOD • IAM
AXIOLATERAL POSITION • Arcuate eminences
• Double Angulation Method • Labyrinths
PP: Prone; head in true lateral, tape auricle • Mastoid antrum
forward; MSP & IOML parallel to IR; IPL • Middle ears
perpendicular to IR • Dorsum sellae w/in shadow of foramen
RP: 2 in. posterior & 2 in. superior to magnum
uppermost EAM
CR: 15° caudad & 15° anterior VALDINI METHOD
• Lange Recommendations: • PA AXIAL PROJECTION
• 25° caudad & 20° anterior PP: Recumbent or seated-erect (more
• Auricles taped forward comfortable); upper frontal region of skull
• Single Angulation Method against IR; MSP perpendicular to IR; head
PP: Prone; tape auricle forward; MSP acutely flexed; IOML 50°/OML 50°; line
rotated 15° toward IR extending from inion to 0.5 cm distal to
RP: 2 in. posterior & 2 in. superior to nasion form 28° to CR
uppermost EAM RP: 0.5 cm distal to nasion (dorsum sellae);
CR: 15° caudad foramen magnum at or slightly above level
Part Angulation Method of EAM (petrosae)
PP: Prone; head rested on flat surface of CR: Perpendicular, inion (entrance); 0.5 cm
check; tape auricle forward; MSP rotated distal to nasion (exit)
15° towards IR; IPL 15° from vertical SS:
RP: 2 in. posterior & 2 in. superior to • DILA (OML 50°): Dorsum sellae; Internal
uppermost EAM Auditory Meatus (IAM); LAbyrinth
CR: 15° caudad & 15° anterior • ETB "EaT Bulaga" (OML 50º): External
SS: Mastoid cells auditory meatus; Tymphanic cavity, Bony
• Sigmoid sinus part of Eustachian tube
• Lateral portion of pars petrosa
• Tegmen tympanic MAYER METHOD
• Superimposed internal & external • AXIOLATERAL OBLIQUE PROJECTION
auditory meatuses PP: Supine; auricles taped forward; outer
• Mastoid emissary vessel (when present) side of IR elevated (reduces part-film
PETREOUS PORTION distance), MSP 45° from IR, chin depressed;
TOWNE METHOD IOML parallel to IR
• AP AXIAL PROJECTION RP: Dependent EAM
PP: Supine; OML/TOML & MSP CR: 45° caudad
perpendicular to IR, SS: APE TEAM
RP: MSP b/n EAMs Axial oblique of petrosa
CR: 30° caudad (OML); 37° caudad (IOMIL) • Petrosa inferior to mastoid air cells
SS: PILAMMD • EAM
• Tympanic cavity & ossicles CR: 45° caudad
• Epitympanic recess (attic) SS: Axial oblique of petrosa
• Aditus • Petrosa inferior to mastoid air cells
• Mastoid antrum • EAM
• tympanic cavity & ossicles
SCHULLER PEEIFER METHOD • Epitympanic recess (attic)
SUBMENTOVERTICAL (SUBBASAL) • Aditus
PROJECTION • Mastoid antrum
PP: Supine or Seated-upright (more Owen Modifications: cited by Pendergrass,
comfortable); OML parallel to IR or CR Schaeffer & Hodes
perpendicular to OML • PP: MSP 40° to IR; IR & head angled 10°
• (cannot fully extend the neck) or caudally
supraorbitomeatal line (SOML) parallel to IR, • CR: 28° caudally
MSP perpendicular to IR, head rested on
vertex, neck hyperextended • Owen Modifications: described by Etter &
RP: ¼ in. anterior to EAM (sella turcica) Cross
CR: Perpendicular to OMI at midway b/n • PP: MSP 30° to IR
EAMs or 15-20* anteriorly at MSP of throat 1 • CR: 25-30° caudally
in. anterior to FAMs
SS: SMALET • Owen Modifications: described by
Symmetric petrosae Compere
• Mastoid processes • PP: MSP 30-45° to IR
• Labyrinths • CR: 30° caudally
• EAM
• Tympanic Cavity • Owen Modifications: used by Zizmor
• Auditory ossicles • PP: MSP 15° to IR
• CR: 35° caudally
EAMS
Tympanic cavities STENVERS METHOD
Acoustic/auditory ossicles • POSTERIOR PROFILE POSITION
• Hirtz Method: PP: Prone; forehead, nose & zygoma
RP: Midway b/n & 1 in. anterior to EAMs against IR (3-pt Upper Landing); IOML
CR: 5° anteriorly parallel to transverse axis of IR; face rotated
away from side of interest; MSP 45° to IR
MAYER METHOD RP: 1 in. anterior to EAM closest to IR (exit)
• AXIOLATERAL OBLIQUE PROJECTION CR: 12° cephalad
PP: Supine; auricles taped forward; outer SS: Pars petrosa closest to IR
side of IR elevated (reduces part-film • Petrous ridge
distance); MSP 45° from IR, chin depressed; • Cellular structure of mastoid process
IOML parallel to IR • Mastoid antrum
RP: Dependent EAM • Area of tympanic cavity
• Labyrinth • KEMP HARPER M ETHOD
• IAM • ERASO MODIFICATION2
• Cellular structure of petrous apex • PP: OML is parallel to IR
• CR: 25 caudad
ARCELIN METHOD • RR: EAM
• ANTERIOR PROFILE POSITION • Eraso modification:
• REVERSE STENVERS METHOD OML 25 degree to IR
• PP: Supine; IOML perpendicular to IR; • CR: 2 inches distal to mandibular
face rotated away from side of interest; symphysis
MSP 45°to IR HYPOGLOSSAL
• RP: 1 in. anterior & ¾ in. superior to EAM AXIOLATERAL OBLIQUE PROJECTION
closest to IR (exit) MILLER METHOD
• CR: 10° caudad • Anterior profile
• SS: Magnified pars petrosa away from IR • PP: supine position; head 45
• ER: Useful with children & with adults who degrees away from the side being
cannot be position for Stenvers Method examined; OML / / to IR

MODIFIED LAW METHOD • CR: 12 caudad; linch inferior of

• AXIOLATERAL POSITION EAM
• Single Angulation Method
• SS: hypoglossal canal
• PP: Prone; taped auricle forward; Head
rotated 15° toward IR; MSP 15°
• RP: 2 in. posterior & 2 in. superior to
uppermost EAM
• CR: 15° caudad
• SS:
• Mastoid cells
• Lateral portion of pars petrosa
• Superimposed IAM & EAM
• Mastoid emissary vessel (when present)

STYLOID PROCESS OF TEMPORAL BONE

PA AXIAL PROJECTION
• CAHOON METHOD
• PP: prone; forehead and nose ; OML
perpendicular
• CR: 25 cephalad
• SS: styloid process of temporal bone

JUGULAR FORAMINA
SUBMENTOVERTICAL AXIAL PROJECTION