Radiographic Position of The Skull PDF

Department of Radiology Techniques The Third stage Radiographic Position of The Skull MSc. Ali Mohammed Radiological Technologist 1 Landmarks Outer canthus of the eye: The lateral point where the upper and lower eyeli...

Department of Radiology Techniques The Third stage Radiographic Position of The Skull MSc. Ali Mohammed Radiological Technologist 1 Landmarks Outer canthus of the eye: The lateral point where the upper and lower eyelids meet. Infraorbital margin/point: The lowest point of the inferior rim of the orbit. Nasion: The junction where the nasal and frontal bones meet. Glabella: A bony prominence on the frontal bone, located just above the nasion. Vertex: The highest point of the skull along the median sagittal plane. External occipital protuberance (inion): A bony prominence on the occipital bone, typically along the median sagittal plane. External auditory meatus (EAM): The opening of the ear that leads to the external auditory canal. Planes Median sagittal plane: Divides the skull into right and left halves; landmarks are the nasion (anterior) and external occipital protuberance (inion) (posterior). Coronal planes: Perpendicular to the median sagittal plane, dividing the head into anterior and posterior sections. Anthropological plane: A horizontal (axial) plane passing through the two anthropological baselines and the infraorbital line. Auricular plane: A coronal plane perpendicular to the anthropological plane, passing through the centers of both EAMs. *The median sagittal, anthropological, and coronal planes are all at right angles to each other. Lines Interpupillary (interorbital) line: Connects the centers of the two orbits or pupils when looking straight ahead. Infraorbital line: Connects the two lowest infraorbital points. Anthropological baseline: Extends from the infraorbital point to the upper border of the EAM. Orbito-meatal baseline (radiographic baseline): Runs from the outer canthus of the eye to the center of the EAM, angled about 10° to the anthropological baseline. Important Note If the front of the head (forehead, nose ,chin) contacts the receptor/cassette, it is a posteroanterior (PA) position. If the back of the head (occipital bone)contacts the receptor/cassette, it is an anteroposterior (AP) position. If the left or right side of the head touches the receptor, it is a lateral projection (left or right, depending on the side) Cranial angulation points the beam towards the head (↑) caudal angulation directs it towards the feet (↓). The prosition is named based on the side of the body closest to the image receptor. True AP or true lateral Position refer to that there is no any rotation in (area of interest) of the organ being imaged.  An oblique projection is obtained when the central ray is angled to both the median sagittal and coronal planes. - The projection is named based on: 1. Whether the anterior or posterior part of the head is in contact with the receptor/cassette. 2. Whether the left or right side of the head is in contact with the receptor/cassette. *Oblique projections become more complex when a caudal (downward) or cranial (upward) angulation is added.This angulation is achieved by: 1.Raising or lowering the chin to adjust the baseline angle relative to the image receptor. 2.Angling the X-ray tube to achieve the desired projection. A combination of both methods may be used, especially for patients with limited mobility. *In true lateral position of Head Alignment: 1. The median sagittal plane should be parallel to the CR cassette, and the interpupillary line should be perpendicular to it. 2. Or the median sagittal plane should be parallel to the Bucky/receptor. Ensure the interorbital line (line between the eyes) is perpendicular to the Bucky/receptor. *For trauma patients, the position may be taken supine and antero- posterior.  203 ×254MM 8x10 18×24CM 254×305MM 10x12 20×40CM 280×356MM 11x14 24×30CM SIZE (Inches) 305×381MM 12x15 30×35CM 356×356MM 14x14 30×40CM 356×432MM 14x17 40×40CM  Lateral – supine with horizontal beam Patient in supine position ,out Bucky Put The Occipital bone (back side of the skull )on non-opaque skull pad to include the occipital region Head adjusted so the median sagittal plane is perpendicular to the table/trolley the interpupillary line is perpendicular to the image receptor(film or cassette). Put IR beside the skull and raise it about 5 cm above the vertex of skull. Direction and Location of X-ray Beam: Collimated horizontal beam directed parallel to the interpupillary line and perpendicular to the median sagittal plane. Centering point midway between the glabella and external occipital protuberance, about 5 cm superior and posterior to the EAM.  Lateral – supine with horizontal beam  Essential Image Characteristics in Lateral – supine with horizontal beam all cranial bones and the 1st cervical vertebrae. A true lateral view will show superimposition of the lateral portions of the floors of both the anterior and posterior cranial fossa. Clinoid Processes: The clinoid processes of the sella turcica should also be superimposed Common Faults and Solutions Fault: Occipital region not included due to inadequate head elevation. Solution: Use a pad or similar support to elevate the head sufficiently from the trolley surface. Fault: Poor superimposition of the lateral floors of the cranial fossa. Solution: Ensure the interorbital line is perpendicular to the cassette/receptor and that the median sagittal plane is perpendicular to the trolley surface.  Lateral erect of skull Patient will be erect and The skull in true lateral position with Bucky Shoulders may be slightly rotated to make the skull in true lateral position The IR should be transversely and its upper border 5 cm above the vertex -Direction and Location of the X-ray Beam X-ray Tube Positioning: Center the X-ray tube to the Bucky/IR. Adjust the height of the Bucky/tube for patient comfort. -Beam Centering: Use a collimated horizontal beam centered midway between the glabella and the external occipital protuberance. CR at a point approximately 5 cm superior and posterior to the EAM. True lateral skull radiograph(there is no any rotation)  Positioning for Occipito-Frontal (OF) Projections of skull Patient in erect position Bucky/IR and skull will be with no rotation The forehead and nose should touching the Bucky without any rotation so we should Recommend the patient to Flex the neck The mid point of forehead should be on the central Bucky and x ray beam should be perpendicular to the Bucky Collimated horizontal beam directed perpendicular to the Bucky/receptor along the median sagittal plane. Collimation and show structures : Include All the cranial bones and skin margins. Caudal Angulated Projections (OF10°↓, OF15°↓, OF20°↓): OF: the petrous ridges should be completely superimposed within the orbit with their upper borders coincident with the upper 1/3 of the orbit. OF10°↓: the petrous ridges appear in the middle 1/3 of the orbit. OF15°↓: the petrous ridges appear in the lower 1/3 of the orbit. OF20°↓: the petrous ridges appear just below the inferior orbital margin.  Fronto-occipital projections of skull The orbits and frontal bone appear magnified due to their increased distance from the image receptor. These projections should only be performed when the patient cannot be moved and must be imaged in a supine position. Increased radiation exposure to the orbits compared to OF projections. Some loss of resolution in anterior skull structures occurs due to the increased object-to-receptor distance.  Fronto-occipital projections of skull The patient in supine position Put The Occipital bone (back side of the skull )on non-opaque skull pad to bring the median sagittal plane at right angles to the image receptor, ensuring it coincides with the midline. Ensure the external auditory meatus (EAMs) are equidistant from the image receptor to avoid rotation. For all FO projections, cranial angulations are utilized. Set the collimated field to include: Vertex of the skull (superiorly) Base of the occipital bone (inferiorly) Lateral skin margins. Specific Angulations (FO10°↑, FO15°↑, FO20°↑): Displace the image receptor superiorly to accommodate for the tube angulation.  Half axial, fronto-occipital 30°Caudal (Towne’s projection) The patient in supine position Put The Occipital bone (back side of the skull )on non-opaque skull pad to bring the median sagittal plane at right angles to the image receptor, ensuring it coincides with the midline The tube angle 30° caudally. The sella turcica of the sphenoid bone should appear within the foramen magnum so The skull should not be rotated; The image must include all of the occipital bone, the posterior parts of the parietal bone, and clearly visualize the lambdoidal suture.  Submento-vertical If the patient is unsteady, use the supine technique for better stability. Supine Positioning Raise the patient’s shoulders and hyperextend the neck to bring the vertex of the skull in contact with the image receptor/gridded CR cassette (or X-ray table). Ensure the external auditory meatus (EAM) is equidistant from the image receptor. Align the median sagittal plane to be at right angles to the image receptor along its midline. Position the orbito-meatal plane as parallel to the image receptor as possible.  Optic foramina – postero-anterior oblique The optic canal opens posteriorly within the bony orbit at the optic foramen. It passes forwards and laterally at an angle of 35° to the median sagittal plane. It also descends at 35° to the orbito-meatal plane. Both sides are typically imaged separately for comparison.  Optic foramina – postero-anterior oblique Patient Positioning of The patient sits erect with the nose cheek, and chin of the examined side in contact with the Bucky/image receptor. The center of the orbit on the side being examined should align with the center of the image receptor. Adjust the median sagittal plane to a 35° angle to the vertical. Raise the orbito-meatal baseline 35° from the horizontal. Use a collimated horizontal central ray aimed at the center of the image receptor. Center the beam to a point 7.5 cm superior and 7.5 cm posterior to the uppermost external auditory meatus (EAM) to ensure the ray emerges from the center of the orbit in contact with the image receptor. A side marker should be positioned above the superior orbital margin for identification.  Jugular foramina – submento-vertical 20° caudal The jugular foramina are located in the posterior cranial fossa, positioned between the petrous temporal bone and the occipital bone, adjacent to the foramen magnum. Both sides are imaged simultaneously using a submento-vertical (SMV) projection with a 20° caudal angle. Position the patient according to the standard SMV projection guidelines previously established. Use a collimated horizontal beam. Angle the central ray caudally to create a 70° angle with the orbito- meatal plane. Center the beam in the midline, directing it to pass midway between the external auditory meatuses (EAMs).  Jugular foramina – submento-vertical 20° caudal  Temporal Bone Imaging: Frontal-Occipital 35° Caudal Projection Patient in Erect or Supine Position Bucky/receptor. Align the external auditory meatuses (EAMs) to be equidistant from the Bucky/receptor. Ensure the median sagittal plane is perpendicular to the Bucky/receptor and positioned in the midline. Depress the chin to achieve a right angle between the orbito-meatal line and the Bucky/receptor. Use a 24 × 30 cm CR cassette, placed transversely in the Bucky tray Tune angle Apply a caudal angulation of 35° to the orbito-meatal baseline. Center the collimated X-ray beam midway between the EAMs. Laterally: Include the lateral margins of the skull. Supero-inferiorly: Include the mastoid and petrous portions of the temporal bone. The mastoid process can be palpated behind the ear pinna for guidance.  Essential Image Characteristics for Temporal Bone Imaging The sella turcica of the sphenoid bone should be clearly projected within the foramen magnum. The skull should not be rotated, confirmed by ensuring that the sella turcica appears centered in the foramen magnum.  Mastoid – lateral oblique 25° caudal The skull should be in true lateral Center the mastoid process in the middle of the Bucky/receptor. If using an 18 × 24 cm CR cassette, position it longitudinally in the Bucky tray, centered with the collimated horizontal beam and the mastoid process. Beam Angulation Apply a 25° caudal angulation to the collimated horizontal beam. Center the beam 5 cm above and 2.5 cm behind the external auditory meatus (EAM), remote from the receptor/cassette. Limit collimation to the mastoid area being examined. Essential Image Characteristics Ensure all mastoid air cells Fault: Failure to center far enough posteriorly may exclude parts of the mastoid air cells from the image. Solution: Double-check the ear's position just before exposure to ensure proper centering.  Mastoid Profile Imaging The patient in supine or erect position rotate the head 35° away from the side being examined. Ensure the mastoid process being examined is centered in the midline of the CR cassette/receptor. Angle the collimated beam caudally so it makes a 25° angle to the orbito- meatal plane. Center the beam to the middle of the mastoid process on the side being examined. Collimate to the margins of the mastoid process for optimal imaging.  Petrous – anterior oblique (Stenver’s) The patient can be prone but is often more comfortable examined in an erect position facing a vertical Bucky/receptor. Center the middle of the supra-orbital margin on the side being examined to the middle of the Bucky/receptor. Flex the neck so that the nose and forehead are in contact with the Bucky/receptor, ensuring the orbito-meatal line is perpendicular to it. Rotate the head toward the side under examination, aligning the median sagittal plane at a 45° angle to the Bucky/receptor. This positioning brings the petrous part of the temporal bone parallel to the receptor. If using an 18 × 24 cm CR cassette, place it transversely in the Bucky tray and center it to coincide with the collimated X-ray beam. Tube angulation Apply a 12° cranially Center the beam midway between the external occipital protuberance and the EAM (External Auditory Meatus) furthest from the Bucky/receptor. Collimate to include the mastoid and petrous parts of the temporal bone being examined.  The occipito-mental projection is designed to visualize the petrous part of the temporal bone below the floor of the maxillary sinuses. This positioning helps in identifying fluid levels or pathological changes in the lower part of the sinuses. The patient is best positioned seated and facing the vertical Bucky/receptor. Have the patient place their nose and chin in contact with the midline of the receptor. Adjust the head to bring the orbito-meatal baseline to a 45° angle relative to the Bucky/receptor. Ensure the horizontal central line of the Bucky/receptor is at the level of the lower orbital margins. Confirm that the median sagittal plane is at right angles to the Bucky/receptor by checking that the outer canthi of the eyes and the EAMs are equidistant. Ask the patient to open their mouth as wide as possible prior to exposure, allowing the posterior part of the sphenoid sinuses to be projected through the mouth.  The occipito-mental projection Beam Positioning: Center the collimated horizontal beam to the Bucky/receptor before positioning. To ensure proper centering, the crosslines on the Bucky/receptor should coincide with the patient’s anterior nasal spine. Collimate to include all of the sinuses. Essential image characteristics The petrous ridges must be positioned below the floors of the maxillary sinuses. No rotation should be present in the image. This can be verified by ensuring that the distance from the lateral orbital wall to the outer skull margins is equidistant on both sides.  Occipito-frontal this projection is specifically designed to visualize the frontal and ethmoid sinuses. The patient is seated, facing the vertical Bucky or skull unit cassette holder. Ensure that the median sagittal plane is aligned with the midline of the Bucky and is perpendicular to it. Position the head so that the orbito-meatal baseline is raised 15° to the horizontal. Ensure that the nasion is centered in the Bucky. If using an 18 × 24 cm cassette, place it longitudinally in the Bucky tray. Adjust the height of the image receptor so that its center coincides with the nasion.  The occipito-mental projection Direction and Location of the X-ray Beam The central ray is directed perpendicular to the vertical Bucky, aligned along the median sagittal plane, exiting at the nasion. Set the collimation field to include the ethmoidal and frontal sinuses. Note that the size of the frontal sinuses can vary significantly between individuals. Essential Image Characteristics Sinus Inclusion: Ensure all relevant sinuses are included in the image. No Skull Rotation: Check for rotation by measuring the distance from a midline point on the skull to the lateral orbital margins. If the distances are equal on both sides, the skull is correctly positioned and not rotated. This projection allows for optimal visualization of the frontal and ethmoid sinuses, aiding in the diagnosis of sinus-related conditions.  This lateral projection is useful for visualizing fluid levels in the sinuses and ensuring proper positioning for accurate imaging. The skull should be in true lateral position. Adjust the head and Bucky heights so that the center of the Bucky/receptor is 2.5 cm from the outer canthus of the eye. If using an 18 × 24 cm CR cassette, position it longitudinally in the erect Bucky with its lower border 2.5 cm below the level of the upper teeth.  Use a collimated horizontal central ray to effectively demonstrate fluid levels. The X-ray tube should be centered to the Bucky/receptor so that the central ray is directed to a point 2.5 cm posterior to the outer canthus of the eye. Essential Image Characteristics True Lateral View: A true lateral projection is achieved when the lateral portions of the floors of the anterior cranial fossa are superimposed. Common Faults and Solutions Patient Position Maintenance: This position can be difficult for patients to maintain. Check the alignment of all anatomical planes immediately before exposure, as the patient may have moved. This projection is crucial for accurately assessing the sinuses and ensuring proper technique to visualize any pathological conditions effectively.  Mandible – Lateral 30° Cranial Projection Position 1 1. The patient lies in a supine position and the skull in true lateral position 2. Slight neck flexion may help clear the mandible from the spine. 3. The lower border of the cassette 2 cm below the lower border of the mandible. 4. In trauma cases where the patient cannot be moved, the projection may be performed with a horizontal beam and the patient will be in supine position and adjust the cassette beside the affected mandible and the skull will be in true AP Position Positioning with the patient’s head on the side.  Mandible – Lateral 30° Cranial Projection The central ray should be angled 30° cranially (upwards) toward the receptor. Superimposition of Mandibular Bodies Occurs if the tube angle is less than 30° or if the centering point is positioned too high. Obscured Region may be occur Due to Shoulder in Horizontal Beam Projection so we should ask the patient to tilt their head toward the side being examined to minimize interference from the shoulder. This positioning technique helps obtain an unobstructed view of the mandible and TMJ by optimizing the X-ray beam's angle and collimation  Mandible – postero-anterior The patient in erect position and the skull in AP position with out any rotiation to Align the median sagittal plane with the midline of the Bucky/receptor. Adjust the head to bring the orbito-meatal baseline perpendicular to the Bucky/receptor. If an 18 × 24 cm CR cassette is used, place it longitudinally in the Bucky and center it at the level of the angles of the mandible. The collimated central ray is directed perpendicularly to the receptor and centered at the midline, aligned with the angles of the mandible.  Mandible – postero-anterior Essential Image Characteristics The entire mandible should be visible, from the lower portions of the TMJs (temporomandibular joints) to the symphysis menti (chin). There should be no rotation evident in the image, which can be verified by checking symmetry across the mandible.  Mandible – Postero-Anterior Oblique This projection is designed to clearly display the symphysis menti and body of the mandible. The patient sits facing the vertical Bucky/receptor. Rotate the head 20° to either side to ensure that the cervical vertebra will be projected clear of the symphysis menti. If an 18 × 24 cm CR cassette is used, place it longitudinally in the Bucky/cassette holder and center it at the level of the angles of the mandible. Direct the collimated central ray perpendicularly to the receptor, centered 5 cm away from the midline on the side opposite the area under examination, at the level of the angle of the mandible.  Mandible – Postero-Anterior Oblique Essential Image Characteristics The symphysis menti should appear clear and free from superimposition of the cervical vertebra.  Temporo-Mandibular Joints – Lateral 25° Caudal Two projections for each side: one with the mouth open and one with the mouth closed. The skull should be in true lateral Alignment: Adjust the head and Bucky height to align the crosslines with a point 1 cm anterior to the EAM along the orbito-meatal baseline. Check that the nasion and external occipital protuberance are equidistant from the receptor. Cassette Position: Using a collimated beam, angle the central ray 25° caudally and center it 5 cm superior to the joint remote from the receptor, so that the beam passes through the TMJ nearest to the receptor.  Temporo-Mandibular Joints – Lateral 25° Caudal Assessment of Joint Dysfunction: TMJ projections are valuable for evaluating joint dysfunction by visualizing erosive and degenerative changes within the temporo- mandibular joints.. Open and Closed Mouth Projections allow for assessment of normal anterior gliding of the mandibular condyle during jaw opening. Observing this motion can reveal mechanical issues or movement restrictions that may indicate joint dysfunction. For greater diagnostic accuracy, MRI is preferred as it provides detailed images of articular cartilage, fibrocartilage discs, and soft tissue behavior during joint movement. This capability makes MRI a superior modality in identifying subtle disc displacements or soft tissue abnormalities not visible on plain radiographs.  Temporo-Mandibular Joints – Lateral 25° Caudal  Temporomandibular Joint (TMJ) X-ray – AP Axial Projection Remove any metallic or plastic objects from the patient’s head and neck to avoid artifacts on the image. The patient can be positioned erect or supine, depending on comfort and condition. If possible, open and closed mouth views are taken for comparison, as per department protocol. Head Position: Rest the posterior part of the skull on the Bucky or table, ensuring the orbitomeatal line (OML) is perpendicular to the image receptor/Bucky. Precaution for Possible Fracture: If a fracture is suspected, avoid having the patient open their mouth. Central Ray: Angle the X-ray tube 35° caudally from the OML. Collimation: Collimate the beam to include both TMJs, ensuring the field is tightly aligned to the condyloid process region for optimal visualization.  Temporomandibular Joint (TMJ) X-ray – AP Axial Projection Image Characteristics Symmetry: No rotation should be present, which is confirmed if the condyloid processes appear symmetrical and are positioned lateral to the cervical spine. AP Axial Projection (Closed Mouth) AP Axial Projection (Closed Mouth)  Facial Bones – Occipito-Mental (OM) Projection This projection is highly effective in detailing facial bone structures and is frequently utilized in trauma cases to assess fractures and other abnormalities in the facial bones. OM radiograph  Facial Bones – Occipito-Mental (OM) Projection The occipito-mental projection is essential for visualizing the floor of the orbits, nasal region, maxillae, inferior frontal bone, and zygomatic bones. This view aims to project the petrous parts of the temporal bone below the inferior maxilla, minimizing obstructions or "noise" in the image. Patient Position: The patient should be erect and seated, facing the Bucky/receptor. Head Position: The nose and chin should rest on the Bucky/receptor. Alignment: Adjust the head to bring the orbitomeatal line (OML) to a 45° angle with the Bucky/receptor. Central Line: The horizontal central line of the Bucky/receptor should align with the lower orbital margins.  Facial Bones – Occipito-Mental (OM) Projection Alignment Check: Ensure the median sagittal plane is perpendicular to the Bucky/receptor by confirming that the outer canthi of the eyes and external auditory meatus (EAM) are equidistant from the Bucky/receptor. Essential Image Characteristics Petrous Ridges Position: The petrous ridges should appear below the floors of the maxillary sinuses. No Rotation: Ensure no head rotation, verified by the equidistant measurement from the lateral orbital wall to the outer skull margins on both sides.  Facial Bones – Occipito-Mental (OM) Projection Modified Mento-Occipital Projection for Facial Bones This projection is useful in trauma settings, where patients are often supine and immobilized, allowing visualization of facial structures while keeping petrous bones clear of the facial bones. Receptor Height: Ensure the top of the CR cassette extends at least 5 cm above the head, to allow for cranial beam angulation. Aligning the Orbitomeatal Line (OML): Check the angle of the OML relative to the receptor: If the OML forms a 45° angle back from vertical (with chin raised), the beam can be directed perpendicularly to the midline at the lower orbital margins. For angles less than 45°, calculate the difference and add the remainder as a cranial angulation to the beam. Example: If the OML angle is 20°, a 25° cranial angulation is required to meet the desired projection angle of 45°.  Facial Bones – Occipito-Mental (OM) Projection Adjust the central ray based on the OML angle to ensure the correct projection. Center the beam to the midline at the level of the lower orbital margins. Collimation: Collimate to include the facial bones and areas of interest, excluding unwanted regions to reduce radiation dose. The projection should effectively show the facial bones with petrous ridges clear of the facial region. This approach accommodates trauma cases and minimizes patient movement, essential for accuracy and patient comfort in emergency settings. Facial Bones – Occipito-Mental (OM) Projection  Occipito-Mental 30° Caudal Projection for Facial Bones for visualizing the lower orbital margins, orbital floors, and zygomatic arches. While it provides enhanced visualization of the arches compared to a standard OM projection, some foreshortening remains. Patient Position: The patient is seated facing the vertical Bucky/receptor. Place the patient’s nose and chin in contact with the Bucky/receptor midline. Adjust the head so that the orbitomeatal baseline (OML) is angled at 45° to the Bucky/receptor. Alignment: Position the horizontal centerline of the Bucky/receptor at the level of the symphysis menti. Ensure the median sagittal plane is perpendicular to the Bucky/receptor by verifying equal distances from the outer canthus of each eye and the external auditory meatuses (EAMs).  Occipito-Mental 30° Caudal Projection for Facial Bones Direction and Location of the X-ray Beam The central ray is angled 30° caudally from horizontal. Beam Centering: Center the beam along the midline to exit at the lower orbital margins. Collimation: Ensure the collimated beam’s crosslines on the Bucky coincide with the upper aspect of the symphysis menti to maintain accurate centering. Key Image Characteristics The petrous ridges should be clear of the orbital floors. Lower orbital margins and zygomatic arches should be well- demonstrated, with minimized rotation indicated by equal spacing between the lateral orbital walls and outer skull margins. Occipito-Mental 30° Caudal Projection for Facial Bones Lateral Projection for Facial Bones (Trauma View) In trauma cases, this projection is taken using a horizontal beam to capture a clear view of the facial bones, ensuring minimal movement and distortion. In Erect Position:The skull should be in true lateral position and the infected side touching the Bucky Adjust the Bucky/receptor height so that its center is aligned 2.5 cm below the outer canthus of the eye. In Supine Position:The patient should be in supine position and the skull will be in true AP position and the cassette will be against the infected side Place the CR 2.5 cm below the outer canthus of the eye. Lateral Projection for Facial Bones (Trauma View) Essential Image Characteristics The resulting image should display all facial bones and sinuses, including the frontal sinus. For a true lateral, the lateral portions of the anterior cranial fossa floor should be superimposed, indicating correct positioning and alignment.  Zygomatic Arches – Infero-Superior Projection (“Jug Handle” View) The patient lies supine, with one or two pillows under the shoulders to fully extend the neck. Place an 18 × 24 cm CR cassette against the vertex (top) of the skull, aligning its long axis parallel to the axial plane of the body. Use foam pads and sandbags to secure the cassette in this position. Adjust neck flexion so that the long axis of the zygomatic arch is parallel to the CR cassette. Tilt the head 5–10° away from the side being examined to prevent superimposition of the skull vault or facial bones over the zygomatic arch. Align the central ray perpendicular to the CR cassette and parallel to the long axis of the zygomatic arch. Center the ray between the midpoint of the zygomatic arch and the lateral border of the facial bones. Use close collimation to minimize scatter and avoid eye exposure.  Zygomatic Arches – Infero-Superior Projection (“Jug Handle” View) The entire length of the zygomatic arch should be visible, clear of any cranial superimposition. If the zygomatic arch overlaps the skull, adjust the head tilt and repeat the image to ensure it is free from superimposition.  Orbits – Occipito-Mental (Modified) Projection This modified occipito-mental projection is commonly used for evaluating orbital injuries, such as orbital floor fractures, and detecting metallic foreign bodies before MRI. Position the patient’s nose and chin against (touching)the midline of the bucky Adjust the head so that the orbito-meatal baseline forms a 35° angle with the image receptor. The skull in true lateral position. The horizontal central line of the Bucky/receptor should be aligned with the midpoint of the orbits. Verify that the median sagittal plane is perpendicular to the Bucky/receptor by ensuring the outer canthi of the eyes and the external auditory meatuses (EAMs) are equidistant from the receptor.  Orbits – Occipito-Mental (Modified) Projection Direct the central ray perpendicular to the cassette holder. Confirm proper centering by aligning the crosslines on the Bucky/receptor with the midline at the level of the mid-orbital region. This positioning will capture a clear image of the orbital region, aiding in accurate assessment of fractures and foreign bodies. Nasal Bones – Lateral Projection This lateral projection is used to evaluate nasal bone fractures and other nasal structure abnormalities. Seat the patient facing an 18 × 24 cm CR cassette supported on the vertical Bucky. The head will be in true lateral position and the nose approximately at the center of the image receptor. Direct a horizontal central ray through the center of the nasal bones.