CHAPTER
Extraoral Projections
and Anatomy
Sotirios Tetradis and Mel L. Kantor
OUTLINE
Selection Criteria Posteroanterior Skull Projection (Posteroanterior
Technique Cephalometric Projection)
Evaluation of the Image Submentovertex (Base) Projection
Lateral Skull Projection (Lateral Cephalometric
Projection)
I
n extraoral radiographic examinations, both the x-ray source
and the image receptor (film or electronic sensor) are placed
outside the patients mouth. This chapter describes the most
common extraoral radiographic examinations in which the source
and sensor remain static. These include the lateral cephalometric
projection of the sagittal or median plane; the submentovertex
(SMV) projection of the transverse or horizontal plane; and the
Waters, posteroanterior (PA) cephalometric, and reverse-Towne
projections of the coronal or frontal plane. Panoramic radiography
is described in Chapter 10, and other more complex imaging
modalities are described in Chapters 11 through 14.
SELECTION CRITERIA
Extraoral radiographs are used to examine areas not fully covered
by intraoral films or to evaluate the cranium, face (including the
maxilla and mandible), or cervical spine for diseases, trauma, or
abnormalities. Standardized extraoral (cephalometric) radiographs
also assist in evaluating the relationship between various orofacial
and dental structures, growth and development of the face, or
treatment progression.
Before obtaining an extraoral radiograph, it is essential to evalu-
ate the patients complaints and clinical signs in detail. The clini-
cian first must decide which anatomic structures need to be
evaluated and then select the appropriate projection or projections.
Selecting the appropriate extraoral radiographic examination for
the diagnostic task at hand is the first step in obtaining and inter-
preting a radiograph. For spatially localizing pathology, usually at
least two radiographs taken at right angles to each another are
obtained.
TECHNIQUE
Extraoral radiographs are produced with conventional dental x-ray
machines, certain models of panoramic machines, or higher capac-
ity medical x-ray units. Cephalometric and skull views require at
least a 20 cm 25 cm (8 inch 10 inch) image receptor. It is criti-
cal to label the right and left sides of the image correctly and
9
Waters Projection
Reverse-Towne Projection (Open-Mouth)
Conclusions
clearly. This usually is done by placing a metal marker (an R or an
L) on the outside of the cassette in a corner in which the marker
does not obstruct diagnostic information.
The proper exposure parameters depend on the patients size,
anatomy, and head orientation; image receptor speed; x-ray source-
to-receptor distance; and whether or not grids are used. In cases
of known or suspected disease, medium-speed or high-speed rare-
earth screen-film combinations provide optimal balance between
diagnostic information and patient exposure. For orthodontic pur-
poses, high-speed combinations reduce patient exposure without
compromising the identification of anatomic landmarks necessary
for cephalometric analysis. Although radiographic grids reduce
scattered radiation and improve contrast and resolution, they result
in higher patient exposure. Cephalometry does not require the use
of grids. However, grids could improve the radiographic appear-
ance of fine structures, such as trabecular architecture, and aid in
the diagnosis of disease.
Proper positioning of the x-ray source, patient, and image
receptor requires patience, attention to detail, and experience.
The main anatomic landmark used in patient positioning during
extraoral radiography is the canthomeatal line, which joins the
central point of the external auditory canal to the outer canthus
of the eye. The canthomeatal line forms approximately a 10-degree
angle with the Frankfort plane, the line that connects the superior
border of the external auditory canal with the infraorbital rim.
The image receptor and patient placement, central beam direction,
and resultant image for the lateral, submentovertex, Waters, pos-
teroanterior, and reverse-Towne projections are summarized in
Table 9-1 and are described in detail in the text. Table 9-1 is
organized to show the progressive head rotation in relation to
the x-ray beam in the frontal views and thus clarify the resultant
projected anatomy.
EVALUATION OF THE IMAGE
Extraoral images should first be evaluated for overall quality.
Proper exposure and processing result in an image with good
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
anatomic landmarks. Interpreting poor-quality images can lead to
diagnostic errors and subsequent treatment errors.
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
for the identification of pathology. Abnormalities cause disrup-
tions of normal anatomy. Detecting the altered anatomy precedes
classifying the type of change and developing a differential diag-
nosis. What is not detected cannot be interpreted.
Interpretation of extraoral radiographs should be thorough,
careful, and meticulous. Images should be interpreted in a room
with reduced ambient light, and peripheral light from the viewbox
or monitor should be masked. A systematic, methodical approach
should be used for the visual exploration or interrogation of the
diagnostic image. A method for the visual interrogation of extra-
oral radiograph of the head and neck is illustrated for the lateral
and PA projections but can be applied to the remaining projections
as well. These methods are not the only approach to examining
radiographic images. Any technique that reliably ensures that the
entire image will be examined is equally appropriate.
LATERAL SKULL PROJECTION (LATERAL
CEPHALOMETRIC PROJECTION)
Of the extraoral radiographs described in this chapter, the lateral
cephalometric projection is the most commonly used in dentistry.
All cephalometric radiographs, including the lateral view, are taken
with a cephalostat that helps maintain a constant relationship
among the skull, the film, and the x-ray beam. Skeletal, dental, and
soft tissue anatomic landmarks delineate lines, planes, angles, and
distances that are used to generate measurements and to classify
patients craniofacial morphology. At the beginning of treatment,
these measurements are often compared with an established stan-
dard; during treatment, the measurements are usually compared
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
treatment.
Image Receptor and Patient Placement
The image receptor is positioned parallel to the patients midsagit-
tal plane. The site of interest is placed toward the image receptor
to minimize distortion. In cephalometric radiography, the patient
is placed with the left side toward the image receptor (U.S. stan-
dards), and a wedge filter at the tube head is positioned over the
anterior aspect of the beam to absorb some of the radiation and
allow visualization of soft tissues of the face. Additional informa-
tion about lateral cephalometry is provided at the end of this
section.
Position of Central X-Ray Beam
The central beam is perpendicular to the midsagittal plane of the
patient and the plane of the image receptor and is centered over
the external auditory meatus.
Resultant Image (Fig. 9-1)
Exact superimposition of right and left sides is impossible because
the structures on the side near to the image receptor are magnified
less than the same structures on the side far from the image recep-
tor. Bilateral structures close to the midsagittal plane demonstrate
less discrepancy in size compared with bilateral structures farther
away from the midsagittal plane. Structures close to the midsagittal
plane (e.g., the clinoid processes and inferior turbinates) should be
nearly superimposed.
Interpretation
Although the lateral cephalometric radiograph is obtained to eval-
uate the relationship of the oral and facial structures, this radio-
graph is still a lateral skull film providing significant diagnostic
information for the head and neck anatomy. As such, lateral cepha-
lometric radiographs should first be evaluated for possible pathol-
ogy and for anatomic variants that might simulate disease, before
cephalometric analysis. It is not sufficient to limit the interpreta-
tion to the cephalometric analysis. To ensure that all anatomic
structures are assessed, a systematic visual interrogation of lateral
cephalometric radiographs should be followed. Such an approach
is presented next (Fig. 9-2):
Step 1. Evaluate the base of the skull and calvaria. Identify the
mastoid air cells, clivus, clinoid processes, sella turcica, sphe-
noid sinuses, and roof of the orbit. In the calvaria, assess vessel
156 P AR T I I Imaging
A B
D E
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
calcifications.
Step 2. Evaluate the upper and middle face. Identify the orbits,
sinuses (frontal, ethmoid, and maxillary), pterygomaxillary fis-
sures, pterygoid plates, zygomatic processes of the maxilla,
anterior nasal spine, and hard palate (floor of the nose). Evalu-
ate the soft tissues of the upper and middle face, nasal cavity
(turbinates), soft palate, and dorsum of tongue.
Step 3. Evaluate the lower face. Follow the outline of the mandible:
from the condylar and coronoid processes; to the rami, angles,
and bodies; and finally to the anterior mandible. Evaluate the
soft tissue of the lower face.
Step 4. Evaluate the cervical spine, airway, and area of the neck.
Identify each individual vertebra, confirm that the skull-C1 and
C1-C2 articulations are normal, and assess the general align-
ment of the vertebrae. Assess soft tissues of the neck, hyoid
bone, and airway.
Step 5. Evaluate the alveolar bone and teeth.
Figure 9-3 presents incidental findings identified on lateral
cephalometric radiographs of asymptomatic orthodontic patients.
Calcification of the intraclinoid ligament and formation of a
bridged sella is a common normal variant that does not warrant
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
and referral to a medical specialist. Multiple opacities throughout
patients calvaria are the result of superimposed hair braids
(Fig. 9-3, C). Well-defined opacities at the superior aspect of
the calvaria represent calcifications of arachnoid granulations
and are a normal variant (Fig. 9-3, D). Enlargement of the
pharyngeal adenoids and palatal tonsils (Fig. 9-3, E) is a common
C
F
finding in young patients but can cause narrowing of the airway
and breathing difficulties. Finally, partial agenesis of the ring
of atlas (Fig. 9-3, F ) is a developmental anomaly that can cause
instability of the atlanto-occipital and atlanto-odontoid articula-
tion and requires further evaluation. The fusion of the body
and transverse process of the dens with the third cervical ver-
tebrae (see Fig. 9-3, F ), which is a rare normal variant, should
also be noted.
After evaluation of the whole lateral skull radiograph for pos-
sible pathology, cephalometric evaluation of the patient follows.
There are many cephalometric analyses based on a variety of
anatomic landmarks. Steiner and Ricketts analyses are two com-
monly used analyses that employ the skeletal, dental, and soft
tissue landmarks listed in Box 9-1. Precise identification of the
various landmarks on the lateral cephalometric radiograph is nec-
essary to generate accurate cephalometric measurements. The
landmarks in Box 9-1 are shown in Figure 9-4, A, on a side view
of a skull and in Figure 9-4, B, on a 5-mm-wide midline section
of an orthodontic patient imaged by cone-beam computed tomo-
graphic imaging. Finally, Figure 9-4, C, depicts the projected
landmark position on the lateral cephalogram of an orthodontic
patient.
POSTEROANTERIOR SKULL PROJECTION
(POSTEROANTERIOR CEPHALOMETRIC PROJECTION)
The second most common skull radiograph used in dentistry is the
PA cephalometric projection. The PA cephalogram is mainly used
for evaluation of facial asymmetries and for assessment of orthog-
nathic surgery outcomes involving the patients midline or
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).

BOX 9-1 Definition of Cephalometric Landmarks
SKELETAL LANDMARKS
1. Porion (P): Most superior point of the external auditory canal
2. Sella (S): Center of the hypophyseal fossa
3. Nasion (N): Frontonasal suture
4. Orbitale (O): Most inferior point of the infraorbital rim
5. PT point: Most posterior point of the pterygomaxillary fissure
6. Basion (Ba): Most anterior point of the foramen magnum
7. PNS: Tip of the posterior nasal spine
8. ANS: Tip of the anterior nasal spine
9. A point (A): Deepest point of the anterior border of the maxillary alveolar ridge
concavity
10. B point (B): Deepest point in the concavity of the anterior border of the
mandible
11. Pogonion (Po): Most anterior point of the symphysis
12. Gnathion: Midpoint of the symphysis outline between pogonion and menton
13. Menton (M): Most inferior point of the symphysis
14. Gonion: Most convex point along the inferior border of the mandibular ramus
15. Ramus point: Most posterior point of the posteroinferior border of the
mandibular ramus
16. R1: Most inferior point of the sigmoid notch
17. R2: Arbitrary point on the lower border of the mandible below R1
18. R3: Most concave point of the anterior border of the mandibular ramus
19. R4: Most convex point of the posterior border of the mandibular ramus
20. Articulare (Ar): Point of intersection between the basisphenoid and the posterior
border of the condylar head
21. Condyle top: Most superior point of the condyle
22. DC point: Center of the condylar head
DENTAL LANDMARKS
23. U6 mesial cusp: Tip of the maxillary first molar mesial buccal cusp
24. U6 mesial: Contact point on the mesial surface of the maxillary first molar
25. U6 distal: Contact point on the distal surface of the maxillary first molar
See Figure 9-4.
Image Receptor and Patient Placement
The image receptor is placed in front of the patient, perpendicular
to the midsagittal plane and parallel to the coronal plane. For the
PA cephalometric radiograph, the patient is placed so that the
canthomeatal line forms a 9-degree angle with the horizontal plane
and the Frankfurt plane is perpendicular to the image receptor. For
the standard PA skull projection, the canthomeatal line is perpen-
dicular to the image receptor.
Position of Central X-Ray Beam
The central beam is perpendicular to the image receptor, directed
from the posterior to the anterior (hence the name posteroante-
rior), parallel to the patients midsagittal plane, and is centered at
the level of the bridge of the nose.
Resultant Image (Fig. 9-5)
The midsagittal plane (represented by an imaginary line extending
from the interproximal space of the central incisors through the
nasal septum and the middle of the bridge of the nose) should
divide the skull image into two symmetric halves. The superior
border of the petrous ridge should lie in the lower third of the
orbit.
C HAP TE R 9 Extraoral Projections and Anatomy 159
26. L6 mesial cusp: Tip of the mandibular first molar mesial buccal cusp
27. L6 mesial: Contact point on the mesial surface of the mandibular first molar
28. L6 distal: Contact point on the distal surface of the mandibular first molar
29. Ul incisal: Incisal edge of maxillary central incisor
30. Ul facial: Most convex point of the buccal surface of the maxillary central incisor
31. Ul root: Root tip of the maxillary central incisor
32. LI incisal: Incisal edge of mandibular central incisor
33. LI facial: Most convex point of the buccal surface of the mandibular central
incisor
34. LI root: Root tip of the mandibular central incisor
SOFT TISSUE LANDMARKS
35. Soft tissue glabella: Most anterior point of the soft tissue covering the
frontal bone
36. Soft tissue nasion: Most concave point of soft tissue outline at the bridge of
the nose
37. Tip of nose: Most anterior point of the nose
38. Subnasale: Soft tissue point where the curvature of the upper lip connects to the
floor of the nose
39. Soft tissue A point: Most concave point of the upper lip between the subnasale
and the upper lip point
40. Upper lip: Most anterior point of the upper lip
41. Stomion superius: Most inferior point of the upper lip
42. Stomion inferius: Most superior point of the lower lip
43. Lower lip: Most anterior point of the lower lip
44. Soft tissue B point: Most concave point of the lower lip between the chin and
lower lip point
45. Soft tissue pogonion: Most anterior point of the soft tissue of the chin
46. Soft tissue gnathion: Midpoint of the chin soft tissue outline between the soft
tissue pogonion and soft tissue menton
47. Soft tissue menton: Most inferior point of the soft tissue of the chin
Interpretation
Similar to the lateral cephalometric projection, the PA cephalo-
gram should be viewed as a skull film first, before any cephalomet-
ric analysis. A systematic review of the radiograph, ensuring
evaluation of all structures, should be followed. Such an approach
is presented next (Fig. 9-6):
Step 1. Evaluate the calvaria, sutures, and diploic space starting in
the area of the left external auditory meatus, over the top of
the calvaria, to the right external auditory meatus. Look for
intracranial calcifications. Identify the mastoid air cells and
petrous ridge of the right and left temporal bones. In this and
all subsequent steps, compare the right and left sides and look
for symmetry.
Step 2. Evaluate the upper and middle face. Identify the orbits,
sinuses (frontal, ethmoid, and maxillary), and zygomatic pro-
cesses of the maxilla. Assess the nasal cavity, middle and inferior
turbinates, nasal septum, and hard palate.
Step 3. Evaluate the lower face. Follow the outline of the
mandible starting from the right condylar and coronoid
processes, ramus, angle, and body through the anterior man-
dible to the left body, angle, ramus, coronoid process, and
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.


A B
D E
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
border of C2, and the inferior border of C1.
Step 5. Evaluate the alveolar bone and teeth.
SUBMENTOVERTEX (BASE) PROJECTION
Image Receptor and Patient Placement
The image receptor is positioned parallel to the patients transverse
plane and perpendicular to the midsagittal and coronal planes. To
achieve this position, the patients neck is extended as far backward
as possible, with the canthomeatal line forming a 10-degree angle
with the image receptor.
Position of Central X-Ray Beam
The central beam is perpendicular to the image receptor, directed
from below the mandible toward the vertex of the skull (hence the
name submentovertex), and centered about 2 cm anterior to a line
connecting the right and left condyles.
Resultant Image (Fig. 9-7)
The midsagittal plane (represented by an imaginary line extending
from the interproximal space of the maxillary central incisors
through the nasal septum, to the middle of the anterior arch of
the atlas, and to the dens) should divide the skull image into two
C HAP TE R 9 Extraoral Projections and Anatomy 161
C
F
symmetric halves. The buccal and lingual cortical plates of the
mandible should be projected as uniform opaque lines. An under-
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.
Interpretation
As described earlier for the lateral and PA cephalometric projec-
tions, a systematic approach that ensures interrogation of the com-
plete image and evaluation of all anatomic structures is paramount
in the interpretation of the SMV projection.
WATERS PROJECTION
Image Receptor and Patient Placement
The image receptor is placed in front of the patient and perpen-
dicular to the midsagittal plane. The patients head is tilted upward
so that the canthomeatal line forms a 37-degree angle with the
image receptor. If the patients mouth is open, the sphenoid sinus
is seen superimposed over the palate.
Position of Central X-Ray Beam
The central beam is perpendicular to the image receptor and cen-
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
from the interproximal space of the maxillary central incisors
through the nasal septum and the middle of the bridge of the
nose) should divide the skull image into two symmetric halves.
The petrous ridge of the temporal bone should be projected below
the floor of the maxillary sinus.
Interpretation
As described earlier for the lateral and PA cephalometric projec-
tions, a systematic approach that ensures interrogation of the
complete image and evaluation of all anatomic structures is para-
mount in the interpretation of the Waters projection.
The central beam is perpendicular to the image receptor and paral-
lel to the patients midsagittal plane and is centered at the level of
the condyles.
Resultant Image (Fig. 9-9)
The midsagittal plane (represented by an imaginary line extending
from the middle of the foramen magnum and the posterior arch
of the atlas through the middle of the bridge of the nose and the
nasal septum) should divide the skull image in two symmetric
halves. The petrous ridge of the temporal bone should be super-
imposed at the inferior part of the occipital bone, and the condylar
heads should be projected inferior to the articular eminence.

REVERSE-TOWNE PROJECTION (OPEN-MOUTH)
Image Receptor and Patient Placement
The image receptor is placed in front of the patient, perpen-
dicular to the midsagittal plane and parallel to the coronal
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,
the patients mouth is opened so that the condylar heads are
located inferior to the articular eminence. When requesting this
image to evaluate the condyles, it is necessary to specify open-
mouth, reverse-Towne; otherwise, a standard Towne view of the
occiput may result.
Interpretation
As described earlier for the lateral and PA cephalometric projec-
tions, a systematic approach that ensures interrogation of the com-
plete image and evaluation of all anatomic structures is paramount
in the interpretation of the reverse-Towne projection.
CONCLUSIONS
Extraoral radiography can provide valuable information for the
evaluation of the dental and craniofacial complex. After assessing
the patients signs and symptoms, the clinician should choose the
proper projection that provides the appropriate diagnostic infor-
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
evaluation of various anatomic structures. Although panoramic
radiography is the subject of Chapter 10, it is included in Figure
9-10 for comparison.
Although most extraoral radiographs in dentistry are cephalo-
metric projections obtained for orthodontic and orthognathic
assessment of asymptomatic patients, anatomic variants that can
simulate disease or affect treatment or even occult pathology can
be identified. As such, cephalometric radiographs should be viewed
as skull radiographs first, and interpreted following a systematic,
thorough, and knowledgeable approach.
Keats TE, Anderson MW: Atlas of normal roentgen variants that may
simulate disease, ed 9, St Louis, 2012, Mosby.
Long BW, Ballinger PW, Smith BJ, et al: Merrills atlas of radiographic
positions and radiologic procedures, vol 2, ed 11, St Louis, 2007, Mosby.
Miyashita K: Contemporary cephalometric radiography, Tokyo, 1996,
Quintessence Publishing Co.
Shapiro R: Radiology of the normal skull, Chicago, 1981, Year Book
Medical Publishers.
Swischuk LE: Imaging of the cervical spine in children, New York, 2001,
Springer-Verlag.

BIBLIOGRAPHY
Kantor ML, Norton LA: Normal radiographic anatomy and common
anomalies seen in cephalometric films, Am J Orthod Dentofac Orthop
91:414426, 1987.