RADIOGRAPHIC TECHNIQUE 4

Section 2

Mammography

Dental imaging
MAMMOGRAPHY TECHNIQUE

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 There are several breast imaging modalities
available such as Ultrasound, CT,Digital
Mammography ,MRI and scintimammography .

 Mammography remains the corner-stone of breast

imaging .

 Only mammography when correctly performed and

interpreted offers the necessary reliability to
diagnose the curable forms of breast cancers.

 Ultrasound,MRI , CT are useful adjuncts once a

lesion has been detected by physical
examination or by radiographic mammography .

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Female Breast
• Consists of 15-20 lobes
– Divided into several
lobules
– Lobules contain
acini, draining ducts
and interlobular
connective tissue.
– By teenage years
each breast contains
hundreds of lobules
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• Breast profile:
• A ducts
• B lobules
• C dilated section of duct to hold milk
• D nipple
• E fat
• F pectoralis major muscle
• G chest wall/rib cage
•
Enlargement:
• A normal duct cells
• B basement membrane
• C lumen (center of duct)
Quadrants of the breast

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Fibro-glandular Breast
• Fibro-glandular
– Dense with very
little fat
– Females 15-30
years of age
• Or 30 years or
older without
children
– Pregnant or
lactating
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Fibro-fatty Breast
• Fibro-fatty
– Average density
• 50% fat & 50% fibro-
glandular
• Women 30-50 years
of age
–Or women with 3
or more children
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Fatty Breast

• Fatty
– Minimal density
– Women 50 and
older
(postmenopausal),
men and children
 Adipose tissue comprises a large portion of most breasts
and is radiolucent.

The radiographically visible densities include

(i)varying degree of ducts

(ii)lobular elements

(iii) fibrous connective tissues structures.

 The supportive connective tissue is highly cellular and

richly vascularised with significant water density-
constitutes the essence of breast opacity in
mammography.
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Sexual hormones influence the degree of hydration of the
adult breast.

The breast is more radiolucent and better contrasted in the

first part of the menstrual cycle

 Pregnancy and lactation make the glandular and connective

tissue structures hypertrophic and more hydrated which leads
to diffuse increase in breast density.

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 INDICATIONS OF MAMMOGRAPHY
 Screening of asymptomatic women
 Screening of high risk women
 Follow up of patients after mastectomy of same and
opposite breast / same breast with implant .
 Investigations of benign breast diseases with
eczematous skin,nipple discharge , skin thickening .
 Investigation of a breast lump
 Investigation of occult primary with secondaries .
 Male breast evaluation . 13
 MAMMOGRAPHY EQUIPMENT
 Generator

 Xray tube – fine focus of 0.2-0.5 mm

with an additional 0.1 mm focus for
magnification .
 Target – Molybdenum and Rhodium

 Beryllium window – Minimises

absorption of
radiation within the tube .
 Molybdenum filter – By transmitting only
characteristic radiation ,absorbs unwanted
radiation and forms a monoenergetic beam.
 Compression device : 1-4 mm thick plastic
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Breast cancer
 Breast cancer is the second leading cause of death from
cancer in women ( lung cancer is first).
 It is widely thought that early detection of breast cancer
leads to more effective treatment and fewer deaths .
 x-ray mammography has proved to be an accurate and
simple method of detecting breast cancer but it is not
simple to perform . The technologist and support staff
must have exceptional knowledge, skill, and caring .
 One important consideration in the overall efficacy of
mammography is the patient dose because radiation can
cause breast cancer as well as detect it.
 However considerable evidence shows that the mature
breast in the age group has very low sensitivity to
radiation–induced breast cancer. The dose necessary to
produce breast cancer is unknown .
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Soft tissue radiography
• Radiographic examination of soft tissues, called soft
tissue radiography, requires selected techniques that
differ from those used in conventional radiography.
• These differences in technique are due to the substantial
differences in the anatomy being imaged .
• In conventional radiography, the subject contrast is great
because of the large differences in mass density and
atomic number among bones, muscle, fat, and lung
tissue. In soft tissue radiography, only muscle and fat
structures are imaged.
• These tissues have similar effective atomic numbers and
similar mass density. Consequently, soft tissue
radiographic technique are designed to enhance
differential absorption in these very similar tissues.
• A prime example of soft tissue radiography is 17
mammography -- radiographic examination of the breast.
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 HEEL EFFECT
 Shape of the breast requires higher intensity of radiation near
the chest wall, to create uniform exposure to the screen-film .
 The cathode is positioned toward the chest wall and the
anode is toward the nipple .

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 SCREEN FILM SYSTEM
 The Xray film should have high resolution and small grain size
and used along with single intensifying screen .
 The emulsion surface of the film must face the screen .

 Prevents loss of resolution due to light diffusion in the screen .

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Full Field Digital Mammography
 Although film screen mammography were effective,
according to various studies up to 20-30% of malignancies
were missed by the regular film screen mammography.
 One of the drawbacks of SFM is its contrast resolution.
 It has been found that women with dense breasts have a
four to six times higher risk of breast cancer compared to
women with little or no glandular tissue. This is postulated to
be due to the masking of existing lesions by the overlying
breast tissue.
 Therefore the sensitivity of mammography in detecting
carcinoma in dense breasts is limited; a 62.9% reduction in
sensitivity in dense breasts as compared to 87.0% in breasts
with fatty involution
 Hence digital mammography was introduced to achieve
better imaging of breasts
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 It works like a DR system
Full Field Digital Mammography (contd.)
 FFDM has a better signal to noise ratio than FSM.
 DM is able to capture areas of contrasting densities and
display these regions without compromising the contrast
resolution very much.
 SFM boasts a high spatial resolution which enables detection
of fine structures such as microcalcification.
 The spatial resolution of DM, however, is limited by pixel size.
Despite this limitation, it has been found that the detection of
microcalcifications on DM is equal to, if not better than, that of
SFM.
 This is due to the increased contrast resolution of DM which
enhances its ability to visualize small high-contrast structures
such as microcalcification
 There is a 45% reduction in the time taken to perform
examinations and process images using DM when compared to
SFM. 22
Advantages
 Higher contrast resolution
 Ability to manipulate to improve image quality and visibility
 Reduced false positives and increased PPV
 Fewer repeat exams for poor exposure. Hence high repeatability
index.
 Faster patient throughput
 Eliminates processing issues
 Simplifies storage and retrieval of images
 Avails possibilities for remote assessing of the images
 Significantly better image acquisition than SFM in women
under 50 years, in pre and peri- menopausal women and in denser
breasts.  Able to do stereotactic biopsy
 Availability of CAD (computer aided detection)
Disadvantages
Expensive 23
Less accurate in patients with fatty breasts
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Positioning, Types and
Techniques
• Clinical data of patients
• Screening mammography
• Diagnostic mammography

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 Clinical Data of Patients
• It is very important to obtain the patient’s history.
• Not only does this help you to better understand your patient, her
needs and anxieties, but it also helps the interpreting radiologist.
History includes
• Gender
• Age
• Age of onset of menses
• Parity (pregnancy history):
– Nulliparity (no pregnancies)
– Multiparity (have they had multiple live births?)
– Age of primiparity (first pregnancy)

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• Menstrual status
– Last menstrual cycle .
– age at menopause
– has she had a hysterectomy and oophorectomy
• Medications
– Estrogen, progesterone, prolactin, thyroid or diabetes
medications, steroids, or estrogen inhibitors
• Previous breast biopsies
– Surgical biopsies and pathologic results
– Core biopsies and pathologic results
– Cyst aspirations
• Previous breast surgery
– Augmentation
– Reduction
– Other (breast lift, tram flap etc.) 27
• Family history of breast cancer
.
– Maternal and paternal
• Miscellaneous:
– Previous chest surgery (open heart, etc.)
– Port-O-Caths
– Moles
– Accessory nipple
– Unusual landmarks

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 Distinction
• Screening mammography
– Used to detect breast changes in women who have no sign,
or symptom, or observable breast anomalies
– The goal is to detect cancer before any clinical signs
are noticeable.
– At least two mammograms from different angles of
each breast
• Diagnostic mammography
– To investigate suspicious breast changes, such as
• a breast lump, breast pain, an unusual skin appearance,
nipple thickening or nipple discharge.
– Also used to evaluate abnormal findings on a
screening mammogram.
– Additional images can be made from other angles or focus30on
Screening Mammography
• In positioning patients for a routine screening
mammogram, the following views are considered
standard for the exam:
– Craniocaudal (CC)
– Mediolateral oblique (MLO)
• Proper breast positioning is based on an
understanding of the normal breast anatomy and the
normal mobility of the breast.
• The mobile aspects of the breast are the lateral
and inferior margins;
• the medial and superior margins are fixed.
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• While it is desirable to have the nipple in profile
.
on the routine views, the primary goal in breast
positioning is to show as much tissue as possible.
• Therefore, breast tissue should not be sacrificed to
show the nipple in profile. The nipple should be
shown in profile, in at least one view.
• When the nipple is not shown in profile on any view,
an extra view for nipple profile can be done.

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 Why use Compression?
• Separates glandular tissue
• Decreases superimposition of tissue
• Improves resolution or clarity of the
image
• Increases contrast to visualize
subtle differences in tissue
• Reduces scatter radiation
• Decreases radiation dose

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CC of a 19 y/o patient CC of a 42 y/o patient

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 MEDIOLATERAL OBLIQUE
VIEW
 Best view to image all of the breast
tissue and the pectoral muscle .

 The C-arm of the mammographic

unit is rotated to 45 degree so that
the cassette is parallel to the
pectoral muscle .

 The film holder is kept high up in the

axillary fossa and the patient s arm
is abducted at the elbow by
80degrees.

 The xray beam enters the breast

from the medial side –compression
is applied to the pectoralis major
muscle .

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 Proper
positioning of
bilateral
mediolateral
oblique view

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 Diagnostic and Additional
Projections
• Exaggerated craniocaudal (XCCL)
• Spot compression
• Cleavage (CV)
• Tangential (TAN)
• Axillary tail (AT)
• Rolled (RL and RM)
• Superolateral to inferomedial (SIO)
• Caudocranial (FB)
• Implant displaced (ID)
• Magnification (M)
• Patients requiring modification of positioning
techniques

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ADDITIONAL VIEWS
Mediolateral view

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Laterally exaggerated craniocaudal view

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• Superior profile illustrating how placement of the flat edge of the
IR against the curved chest wall excludes a portion of the breast
tissue (shaded area).

• Dashed line indicates placement of IR for exaggerated position.

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 Spot Compression view
• Spot or coned compression is a simple technique.
It is especially helpful with obscure or equivocal
findings in areas of dense tissue.
• Spot compression allows for more localized
compression of an area of the breast. It allows for
higher contrast, and more precise evaluation of
findings.
• Using the original mammogram, the technologist
determines the placement of the small compression
device by determining the location of the lesion.

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 .
• To determine the location of the lesion, measure the
depth relative to a line drawn directly posterior from
the nipple, the distance from that line to the lesion in
the superior-to inferior or medial-to- lateral
direction, and the distance from the lesion to the skin
surface.
• Reposition the patient, using your hand to simulate
compression.
• Transfer the three measurements to the breast and
use a marker to identify the location of the lesion.
• Reposition to center the spot compression device
over the lesion. 52
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Spot compression
of suspicious area
containing
microcalcifications

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 Cleavage (CV)
• The cleavage view (valley view, double breast
compression view) is performed to visualize deep
lesions in the posteromedial aspect of the breast.
• The patients head is turned away from the side of
interest.

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 Tangential (TAN)
• This view is used for palpable
lesions that are obscured by
surrounding dense glandular
tissue on the mammogram.
• These views can be obtained by
placing a lead marker (BB)
directly over the lump and
directing the X-ray beam
tangential to the lead marker.
• These views can also be used
to verify that calcifications
seen on a mammogram are
located within the skin.
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A tangential projection with spot compression
of the localized area demonstrating benign
dermal calcifications

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 Axillary Tail (AT)
• This view is used to demonstrate the entire axillary tail as
well as most of the lateral aspect of the breast.
• The patient is turned to bring the axillary tail in contact
with the cassette holder.The patient’s arm on the side being
imaged is draped behind the top of the cassette holder.

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• Gently pull the axillary aspect of the breast out and away
from the chest wall and place it on the cassette holder. Hold
the axillary tail in place while slowly applying
compression.

Mediolateral oblique
projection for AT of a 68-
year-old woman,
demonstrating ill- defined
stellate mass measuring 8
mm
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 Rolled (RL and RM)
• The roll view is used to separate superimposed
breast tissues. The purpose is to confirm the
presence of an abnormality, to better define a
lesion, or to determine the location of a finding
seen on only one of the standard views.
• Placing your hands on either side of the breast,
“roll” the tissue in opposite directions.
• Compression will maintain the breast in the “rolled”
position. A radiopaque marker indicating the direction
of the roll should be placed on the image receptor.

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Craniocaudal projection with roll
lateral (RL) 65
 Magnification (M)
• Magnification views with or without spot compression can
be helpful in differentiating benign from malignant lesions
by permitting a more precise evaluation of margins and
other architectural characteristics of a focal density or
mass.
• These views also permit better delineation of the number,
distribution and morphology of calcifications.
• To perform magnification views, there has to be an X-ray
tube with a micro focal spot to offset the geometric
unsharpness. It also requires a magnification platform to
separate the compressed breast from the cassette for a 1.5 to
2.0 times magnification. In making the exposure, the patient
will need to hold still longer than for a normal mammogram.
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 How mammogram are read?
• Its challenging must be interpreted by radiologist
• Must to compare with previous mammogram

Changes in breast tissue

• Calcification: macrocalcification
microcalcification
• Mass
• Breast density

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 Calcification:
Macrocalcification
• Due to changes in breast caused by aging of
breast arteries, old injuries or inflammation
• Coarse/ large Calcium deposit
• Seen in 1 0f 10 women under 50 and about half over 50
These deposit are related to Non-cancerous condition and do not
require biopsy
Microcalcifiation
• Tiny specks of calcium
• If seen it’s a matter of concern though not necessarily it is cancer
but needs biopsy

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 Mass
• Mass with or without calcification
• Noncancerous mass:
Cystic– fluid filled sacs/ simple cyst
Solid – Fibro adenoma
• Complex or mixed mass: suspect cancer
needs FNAC or biopsy
Breast ultrasound is complementary

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 Breast density
• Density is based on
: how much fibrous and glandular
tissue
: how is the distribution within breast
tissue
: how is breast made up of fatty tissue
Dense breasts are not abnormal but they are
linked to higher risk of breast cancer
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 Findings on mammogram
• Primary signs of breast cancer may include spiculated
masses or clustered pleomorphic microcalcification
• Secondary signs of breast cancer may include
asymmetrical tissue density, skin thickening or
retraction or focal distortion of tissue
Impression
• Overall assessment of the radiological findings often
includes a classification of the mammogram using
the BI-RADS system developed by the American
College Of Radiology(ACR)
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 Recommendation(optional)

• No action necessary
• A six month follow up mammogram
• Spot views
• Breast ultrasound
• Biopsy etc….

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BI-RADS
 CATEGORY 0 -Need additional Imaging evaluation\

 CATEGORY I - Negative

 CATEGORY 2 -Benign finding

 CATEGORY 3 -Probably benign findings

 CATEGORY 4 -Suspicious abnormality

 CATEGORY 5 -Highly suggestive of a malignancy

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Mammogram - normal

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Mass on mammogram

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Mass on mammography

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Tissue density on mammogram
Fatty versus dense

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FINE NEEDLE ASPIRATION (FNA)
A needle biopsy is performed under local anesthesia. Simple
aspirations are performed with a small gauge needle to
attempt to draw fluid from lumps that are thought to be
cysts. Fine needle biopsy uses a larger needle to make
multiple passes through a lump, drawing out tissue and
fluid. Withdrawn
fluid and tissue is
further evaluated
to determine if
there are
cancerous cells
present.

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SURGICAL BIOPSY
An open biopsy can be performed under local or general
anesthesia and will leave a small scar. Prior to surgery, a
radiologist often first marks the lump with a wire, making
it easier for the surgeon to find

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A. Mammogram with localizing wire
B&C X ray of the specimen showing wire and surrounding tissue

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 Male Breast Cancer Statistics:
• According to the American Cancer Society,
about 0.22 percent of men’s cancer deaths
are from breast cancer.
• This disease is 100 times more common in
women than it is in men.
• Thanks to greater awareness and better
treatments, the survival rates for both men
and women are on the rise.

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ULTRASOUND OF THE BREAST
ROLE OF ULTRASOUND AND INDICATIONS
Ultrasound is a valuable diagnostic tool in assessing the
following indications: 
•Investigating a palpable lump
•Mammography abnormality
•Follow up of known lesion
•Mastalgia
•Nipple discharge
•Infection or mastitis
•Guidance for biopsy or hookwire localisation
Ultrasound increasingly enlisted as part of a comprehensive
screening program along side mammography.
LIMITATIONS
Extremely large, mobile breasts will be difficult to scan
thoroughly.
Post injury, surgery or biopsy, the resultant haematoma will
reduce detail and may obscure pathology
EQUIPMENT SELECTION AND TECHNIQUE
Breast u/s requires a high frequency transducer 8-15 MHz.
Ideally a wide footprint probe.
A lower frequency transducer may be required for the
larger attenuative breasts, inflammatory masses and the
axilla.
The use of a stand off may be required for nipple,
superficial/or skin lesions.
Low PRF color and spectral doppler capabilities for
assessing vascularity of lesions.
PATIENT POSITION

Patient supine
You may need to roll the patient slightly to 'spread' the
breast evenly. Elevate the side being scanned with a wedge
under the shoulder.
Raise the ipsilateral arm over the patient's head.
It is important to correlate the ultrasound with any palpable
lumps indicated by the patient. Accordingly, if the patient can
only identify the lump when she is erect than rescan the
patient erect.
SCANNING TECHNIQUE
The most common scanning technique is to initially scan using
the grid scanning pattern, followed by a radial (clock face)
technique for the hard copy imaging.
1- GRID SCANNING PATTERN
Scan up and down the breast in rows, making sure you
overlap each row slightly to ensure no breast tissue is
overlooked.
Begin in the upper outer quadrant, scanning in transverse.
Slide inferiorly from top to bottom.
Move across and repeat the sweep inferior to superior.
Repeat this across the breast.
Rotate into a sagittal plane and repeat the pattern.
A variation, particularly in larger or mobile breasts, is to
apply the grid pattern quadrant by quadrant
 .
GRID SCANNING TECHNIQUE
 2- RADIAL SCANNING PATTERN (Clock-face)
The breast is scanned and described as a clock-face.
Begin at 12 o'clock in a sagittal plane with the toe of the
probe at the nipple.
Scan by rotating the probe around the nipple.
Depending on breast size, a second pass further from the
nipple may be required.
If pathology is identified, rotate the probe 90degrees in the
'anti-radial' plane.
Radical Scanning Pattern
Normal Breast Tissue
 BREAST LESIONS
CYST FIBROADENOMA
 Breast Lesions
Malignant Mass Intra ductal Mass
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 DENTAL
IMAGING

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 Introduction to the dental anatomy
A tooth can be divided into two main parts: the
crown and root.
Found above the gum line, the crown is the enlarged
region of the tooth involved in chewing. Like an actual
crown, the crown of a tooth has many ridges on its top
surface to aid in the chewing of food.
Below the gum line is the region of the tooth called the
root, which anchors the tooth into a bony socket
known as an alveolus

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 113
Gum Alveolus
Each tooth is an organ consisting of three layers: the
.pulp, dentin, and enamel
The pulp of the tooth is a vascular region of soft
connective tissues in the middle of the tooth. Tiny blood
vessels and nerve fibers enter the pulp through small
holes in the tip of the roots to support the hard outer
structures. Stem cells known as odontoblasts form the
dentin of the tooth at the edge of the pulp.

114
Surrounding the pulp is the dentin, a tough, mineralized
layer of tissue. Dentin is much harder than the pulp due to
the presence of collagen fibers and hydroxyl apatite, a
calcium phosphate mineral that is one of the strongest
materials found in nature. The structure of the dentin layer
is very porous, allowing nutrients and materials produced
in the pulp to spread through the tooth.

115
The enamel – the white, outer layer of the crown –
forms an extremely hard, nonporous cap over the
dentin. Enamel is the hardest substance in the body and
.is made almost exclusively of hydroxyl apatite
Teeth are classified into four major groups:
incisors, canines, premolars, and molars.
Incisors are chisel-shaped teeth found in the front of
the mouth and have a flat apical surface for cutting food
into smaller bits.

116
Canine teeth, also known as cuspids, are sharply
pointed, cone-shaped teeth that are used for ripping
tough material like meat. They flank the incisors on
.both sides
Premolars (bicuspids) and molars are large, flat-
surfaced teeth found in the back of the mouth. Peaks
and valleys on the flat apical surface of premolars and
molars are used for chewing and grinding food into tiny
pieces.
Babies are born without teeth, but grow a temporary
set of twenty deciduous teeth (eight incisors, four
canines, and eight molars) between the ages of six
months and three years.

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The first twenty-eight adult teeth are fully erupted by the age of
eleven to thirteen with the third molars, known as wisdom teeth,
erupting in the back of the jaw several years later in early
adulthood.
Sometimes the wisdom teeth become impacted when they grow
and become wedged at an abnormal position in the jaws and fail
to erupt. In some cases there is not enough room in the jaw to
accommodate a third set of molars. In both cases the wisdom
teeth are surgically removed, as they are not needed to properly
chew food.

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 3rd Molar or Wisdom Teeth
What are wisdom teeth? Most of us will develop a
third molar tooth in each quadrant of our mouths,
upper left, upper right, lower left lower right. The
molars are the large grinding teeth in back. The last
molars in the line are called 3rd molars or more
popularly wisdom teeth. These teeth usually erupt;
break through the gum tissue after the age of 17.
Some will only partially erupt and others will stay
completely buried under the tissue. Many patients
never develop 3rd molars although a few folks will
get 4th molars. Fortunately, these are rare.
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 ?What is an impaction
If a tooth never comes through the gum tissue and is
covered by tissue or bone it is referred as "being
impacted." To remove impacted teeth, the tissue must
first be opened and often bone must be removed to get to
the tooth. In order to keep the hole as small as possible,
the teeth may be cut into several small pieces so each
piece can be removed more easily. After this type of
extraction, there is usually swelling and moderate to
.severe pain requiring potent pain killers for a few days

121
Baby teeth fill the child’s tiny jaws and allow the child to
chew food while larger, stronger adult teeth develop inside
the mandible and maxilla bones. At about six years of age
the deciduous teeth are slowly shed one at a time and
.replaced by permanent adult teeth

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Dental anatomy

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 The Radiographic Film
• Available in different sizes,
e.g. size 0, 1, 2, 3

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 Film Holders

Dental X-ray Unit

X-ray Viewer
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Dark Room
TYPES OF DENTAL RADIOGRAPHS
1. Extraoral Radiographs (Indirect Exposure)
– OPG / DPT
– Lateral Ceph
– PA view

2. Intraoral Radiographs (Direct Exposure)

– Bitewing Radiographs
– Occlusal Radiographs
– Periapical Radiographs

133
 BITEWING RADIOGRAPHS

INDICATIONS
– Routine radiograph at regular dental checkups
– Proximal Caries
– Monitoring of progression of caries
– Overhanging restorations
– Diagnosis of Periodontal disease

134
• Bitewing (also called interproximal )
radiographs include the crowns of the
maxillary and mandibular teeth and the
alveolar crest on the same receptor.
• CR Parallel with the occlusal plane.

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 Periapical Radiographs
– Image of whole length of tooth & surrounding bone.

– Allows comparison between pre & post op

condition

– To undertake procedures as swiftly as possible to

minimize patient discomfort

136
 Indications
• Assessment of periodontal status
• Endodontics
• Assessment of apical surgery
• Detection of apical cyst
• After dental trauma
• Assessment of root morphology before extraction

Techniques
• Paralleling film Or Paralleling Technique
• Bisecting Angle Technique
• SLOB Technique
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 .

l
The resulting radiograph shows a ingual
s
object that moved in ame direction as cone
b
and uccal object that moved in opposite
direction

138
 Occlusal Radiographs
• INDICATIONS
• Detecting the presence of unerupted teeth,
supernumaries and odontomes
• Determining the bucco-lingual relationship of objects

• Evaluation of the size and extent of lesions such as cysts

or tumors
• Assessment of fractures of the jaw
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Panoramic Radiography/
(OPG)
Panoramic radiography ( rotational
radiography) is a radiographic procedure that
produces a single image of the facial
structures, including both maxillary and
mandibular arches and their supporting
structures

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 Advantages
• Broad anatomic region imaged
• Positioning is relatively simple
• Relatively less radiation dose (about one third of the
dose from a full mouth survey of intra-oral films)
• View of both sides of the jaws is useful in the assessment
of fractures
• Over all view is helpful for initial assessment of
periodontal status
• Antral floor can be seen
• Both condylar heads are shown on one film, allowing
easy comparison
• Procedure can be performed in patients of limited mouth
opening 143
 Disadvantages
• Resultant image does not resolve the fine anatomic
detail that may be seen on intra oral peri-apical
radiograph
• Soft tissues and air shadows can overlie the required
hard structures
• Technique is not suitable for children because of length
of exposure cycle
• Cost of machine is almost double or four times than that
of intra-oral machine

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 Indications
• Orthodontic assessment
• Lesions like cyst,tumors and development anomalies in the
body and rami of mandible to establish the site and size
• Fractures of mandible
• Antral diseases, especially to asses the floor, posterior and
anterior walls of antrum
• To investigate the quality of articular surface of the condylar
heads
• Periodontal diseases; an overall view of alveolar bone levels
• Assessment of the presence and position of wisdom teeth
• Assessment of any underlying disease before construction of
prosthesis
• Evaluation of vertical height of bone before insertion of
implants
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