1. Facial Bone, Nasal Bone Anatomy, Facial Bone, Nasal Bone Projections
Week 6
Facial Bone, Nasal Bone Anatomy, Facial Bone, Nasal Bone Projections

2. 14 bones in the face, not including the hyoid bone
FACIAL BONES
14 bones in the face, not including the hyoid bone
6 paired bones
2 unpaired bones

3. Nasal
bone 13 2 1 3 4 11 10 6 7 9
There are 14 bones that make up the facial bones. 6 of which are paired and 2 single bones: mandible and vomer.
The facial bones contribute to the shape and form of a person’s face. They also serve as protective housing for the eyes. There are cavities of the orbits, nose and mouth that are largely made up of the facial bones.
2 Maxillae
2 Zygomatic bones
2 Lacrimal bones
2 Nasal bones
2 Inferior nasal conchae
2 Palatine bones (not visualized
1 vomer
1 mandible 8 8 5

4. Nasal Bones Two small, thin bones
Vary in size and shape in individuals
Form superior bony wall of nasal cavity
Commonly called “bridge of nose”
Articulations
With each other in midsagittal plane
Superior = frontal bone
Posterosuperior = perpendicular plate of ethmoid bone
On each lateral side = maxillae
Nasion is the junction of nasal bone and frontal bone

5. Lacrimal Bones The two smallest bones in the skull
Located in anterior part of medial wall of orbits between labyrinth of ethmoid and maxilla
Each bone contains a lacrimal foramen through which the tear duct passes
Articulations
Frontal
Ethmoid
Maxilla
Inferior nasal concha
Smallest and most delicate bones in face

6. Maxillary Bones Largest immoveable bones of face
Each articulates with all other facial bones, except for mandible
Also articulate with frontal and ethmoid cranial bones
Form part of lateral walls and most of floor of nasal cavity
Form part of floor of orbit
Articulates with 2 cranial bones- Frontal and ethmoid
Articulates with 7 facial bones -zygomatic, nasal, palatine, inferior nasal concha, vomer, opposite maxilla

7. Maxillary Bones Form three fourths of roof of mouth
Have zygomatic process that articulate with zygoma to form part of cheek
Body contains large, pyramidal cavity = maxillary sinus
Infraorbital foramen = located under each orbit for passage of infraorbital nerve and artery
The 2 maxillae are the largest immovable bones of the face. The maxillae and united at the midline below the nasal septum.
Each maxillae assists is forming three cavities: mouth, nasal cavity, and one orbit.
Each maxillae consists of 4 processes: 1) frontal process 2) zygomatic process 3)Alveolar process 4) Palatine processes
1) Frontal process projects superiorly along the lateral border of the nose toward the frontal bone.
2) Zygomatic process extends laterally toward the zygoma on each sided.
3) Alveolar process is the inferior aspect. Along the inferior margin of each alveolar process are 8 upper teeth.
4) Palatine process can only be demonstrated inferiorly and form the anterior portion of the mouth called the hard, or bony palate.
This bone also contains and important landmark for radiography of the skull and facial bones: acanthion. The acanthion is at the base of the anterior nasal spine at a point where the nose and upper lip meets.
The maxillae contain pyramidal shaped cavities called the maxillary sinuses.
The infraorbital foramen is located under each orbit on each maxillae which serves as a passage through which infraorbital nerve and artery reach the nose.
The maxillae articulate with 2 cranial bones: frontal and ethmoid. Also articulates with all facial bones with the exception of the mandible.

8. Maxillary Bones
Alveolar process = inferior borders of spongy bone that support roots of teeth
Anterior nasal spine = forward, pointed process at their midline junction
Acanthion = midpoint of this junction
Maxilla helps form 3 facial cavities: nasal cavity, oral cavity and orbits
Frontal process helps form the lateral border of nasal cavity, and medial wall of orbit
Palatine process helps form anterior portion of hard palate
Largest immovable facial bone

9. Maxillary Bone

10. Palatine Bones
Two L-shaped bones composed of vertical and horizontal plates
Horizontal plates articulate with maxillae to complete the posterior fourth of bony palate (roof of mouth)
Vertical portions extend upward between maxillae and pterygoid processes of sphenoid in posterior nasal cavity
Superior tips of vertical plates assist in forming posteromedial orbit

11. Palantine Bones
Cut away view of face: palatine bone not seen on frontal view
Helps form oral cavity, small portion of orbit

12. Hard Palate Inferior view of hard palate:
Maxilla forms the anterior portion, the horizontal portion of palatine forms the posterior ¼th.
Congenital defect: opening in between the palatine processes of the maxilla….Cleft palate
NOTE: pterygoid hamulus of sphenoid bone….cranial bone articulation

13. Inferior Nasal Conchae
Extend diagonally and inferiorly from lateral walls of nasal cavity at its lower third
Long, narrow, very thin bones with a lateral curl
Gives scroll-like appearance
Upper two nasal conchae are processes of ethmoid bone
The superior and middle nasal conchae are processes of the ethmoid bone, while the inferior nasal conchae are separate facial bones.
The inferior nasal conchae are thin, narrow and extremely thin bones which curl laterally and look like miniature scrolls.
The inferior nasal conchae articulate with the ethmoid bone and the maxilla, lacrimal and palatine bones.

14. Inferior Nasal Concha

15. Zygomatic Bones Articulations Superior = frontal bone
Lateral = zygomatic process of temporal bone
Anterior = maxilla
Posterior = sphenoid
Forms “cheek” of the face
Another name is malar bone
Articulates with 3 cranial bones-frontal, temporal, sphenoid
Articulates with only one facial bone-maxilla

16. Zygomatic Bones
Together with the zygomatic process of temporal bone and the temporal process of zygomatic bone forms the zygomatic arch
Zygomatic prominence is a palpable landmark
Zygomatic arch is easily fractured. Specialized views taken. Will be reviewed later.

17. Vomer Thin plate of bone situated in MSP of floor of nasal cavity
Forms inferior nasal septum
Superior border articulates with body of sphenoid bone
Superior part of anterior border articulates with perpendicular plate of ethmoid bone
Posterior border is free
Together the perpendicular plate of the ethmoid bone and the vomer form the bony nasal septum. Anteriorly the septal septum is cartilaginous and is called the septal cartilage.
A deviated nasal septum describers the clinical condition where the nasal septum is displaced laterally from the midline of the nose. This deviation occurs at the site of the septal cartilage and the vomer. If there is a severe deviation the nasal passageway can be blocked, not allowing the patient to breathe from their nose.
The vomer has small furrow-like depressions for blood vessels. In a trauma this can be a source for nosebleed.
Articulates with the sphenoid and ethmoid bones of the cranium.
Articulates with the R/L palatine bones and the R/L maxillae.

18. Vomer Cut away diagram, Vomer is not readily seen on lateral view
Notice the posterior border-does not articulate with any bone

19. Mandible Largest and densest bone of the face
Body = curved horizontal portion
Rami = two vertical portions on each side of body
Angle of mandible = junction of body and ramus
Also called gonion
Mental protuberance = anterior, triangular prominence

20. Mandible
Symphysis = most anterior and central part where left and right halves of mandible fuse
Alveolar process = superior border of body; consists of spongy bone that supports roots of teeth
Mental foramina = small openings on each side below the second premolar; transmit nerves and blood vessels

21. Mandible Coronoid process = anterior process on top of ramus
Condylar process = posterior process on top of ramus; articulates with mandibular fossa of temporal bone to form temporomandibular joint (TMJ)
Mandibular notch = concave area at top of ramus between coronoid and condylar processes

22. Anterior and lateral aspects of mandible
Anatomy: Mandible
Anterior and lateral aspects of mandible

23. Hyoid Bone Small U-shaped bone situated at the base of the tongue
Accessory bone of axial skeleton – not a facial or cranial bone
Only bone in the body that does not articulate with another bone

24. Lateral aspect of facial bones
Anatomy: Facial Bones
Lateral aspect of facial bones

25. Clicker Question Which facial bones form part of the hard palate?
Palatine
Mandible
Zygoma
Lacrimal
A – Palatine

26. Clicker Question
All of the following are part of the bony orbit, except:
Palatine
Zygoma
Lacrimal
Vomer
D – Vomer

27. Essential Projections: Facial Bones
Lateral
Parietoacanthial (Waters method)
Acanthioparietal (reverse Waters method)
Posteroanterior (PA) axial (Caldwell method)

28. Lateral Facial Bones Patient position Part position
Semi-prone or seated in upright anterior oblique
Part position
MSP of head parallel with image receptor (IR)
Interpupillary line (IPL) perpendicular to IR
Infraorbitomeatal line (IOML) perpendicular to front edge of IR
Note the difference phrasing of the positioning of the IOML. This is the EXACT same position as in the cranium but since the collimation is different…but it sounds like it is changed.
Long axis of collimated area is now vertical, not horizontal as in lateral view of cranium.

29. Lateral Facial Bones Central ray (CR) Collimated field
Perpendicular to IR center
Enters patient on lateral surface of zygomatic bone halfway between outer canthus and external acoustic meatus (EAM)
Collimated field
8 x 10 inches (18 x 24 cm)

30. Lateral facial bones Zygomatic bones superimposed and centered
Mandibular rami S/I (no rotation)
Orbital roofs and greater wings of sphenoid are S/I (no tilt)

31. Lateral facial bones

32. Lateral facial bones
Frequently collimated to 8x10 field

33. PA Axial (Caldwell) Patient position Part position
Seated erect or prone
MSP centered to midline
Forehead and nose resting on table or upright Bucky
Part position
OML perpendicular to IR plane
MSP perpendicular to IR
IR centered to nasion
Petrous ridges in lower 1/3 (proper angulation)
Crista galli equidistant to outer orbital margin, superior orbital fissures symmetrical (rotation)
Petrous at same level (tilt)
If petrous ridges are shown in the lower ½ of orbits. What positioning error? How fix?

34. PA Axial (Caldwell) CR Collimated field Angled 15 degrees caudad
Exits nasion
For orbital rims, angle 30 degrees caudad (“exaggerated” Caldwell)
Collimated field
10 x 12 inches (24 x 30 cm)
Orbital rim, maxillae, nasal septum, zygomatic bones and anterior nasal spine

35. PA Axial (Caldwell)

36. PA Axial(Caldwell)
Orbital rims, superior orbital fissures, crista galli, inferior nasal concha,

37. PA Axial (Caldwell)
Notice the parietal bones have been clipped. Is this cause for repeat?

38. Parietoacanthial (Waters) Facial Bones
Patient position
Prone or seated upright
Center MSP to midline of upright Bucky
Be sure to practice both types of positioning, upright and prone in lab.
Water’s view frequently done for air-fluid levels.

39. Parietoacanthial (Waters) Facial Bones
Part position
Rest head on tip of extended chin
Place orbitomeatal line (OML) to form 37-degree angle with plane of IR
Mentomeatal line (MML) perpendicular to IR
MSP perpendicular to IR
Center IR to level of acanthion

40. Parietoacanthial (Waters) Facial BonesCR
Perpendicular to exit acanthion
Collimated field
8 x 10 inches (18 x 24 cm)

41. Parietoacanthial (Waters) Facial Bones
Note position of nose, ¾ “ away from IR

42. Parietoacanthial (Waters) Facial Bones

43. Parieto-acanthial (Waters) Facial Bones
It is important that the petrous ridges lie below the maxillary sinuses.

44. Parietoacanthial (Waters) Facial Bones

45. Parietoacanthial (Waters) Facial Bones

46. Water’s view with accurate positioning
What do you think the artifact is?

47. Parietoacanthial (Waters) Facial Bones
Modifications for the Water’s projection:
done to see entire orbital rims
OML at a 55° angle to IR
(use the LML for positioning)
petrous ridges just below IOM

48. Parietoacanthial (Waters) Facial Bones-Modified

49. Parieto-acanthial (Waters) Facial Bones
Modifications for the Water’s projection:
Done in order to better see the entire orbital rims
Petrous rideges in lower ½ of maxillary sinus
Orbital floors should be centered in image.

52. Acanthioparietal (Reverse Waters) Facial Bones
When patient cannot be upright or prone, usually due to trauma

53. Acanthioparietal (Reverse Waters) Facial BonesCR
Perpendicular to enter acanthion
Center IR and CR
Collimated field
10 x 12 inches (24 x 30 cm)
Patients will have difficulty in getting MML ⊥ to IR, if they cannot, then angle CR so it is ∥ to MML

54. Acanthioparietal (Reverse Waters) Facial Bones

55. Acanthioparietal (Reverse Waters) Facial Bones

56. Acanthioparietal (Reverse Waters) Facial Bones

57. Acanthioparietal (Reverse Waters) Facial Bones

58. Acanthioparietal (Reverse Waters) Facial Bones
Patient with difficulty in positioning MML ⊥ to IR so change CR angle to be ∥ to MML
Be sure to practice this position in lab.

59. Essential Projections: Nasal Bones
Lateral
Water’s
Caldwell
A nasal bones series often includes a Modified Water’s, a PA axial (Caldwell), or a modified Caldwell
Both these images will demonstrate deviation of bony nasal septum or fluid levles in sinuses due to trauma.

60. Lateral Nasal Bones Patient position Part position Semiprone
MSP of head horizontal
Part position
MSP parallel with tabletop
IPL perpendicular to tabletop
IOML is parallel with transverse axis of IR
Note the wording on the IOML.
Used to be done on one film. Used detail film for imaging.
Needs to be tightly collimated.

61. Lateral Nasal Bones CR Collimated field
Perpendicular to bridge of nose
Enters at a point ½ inch (1.3 cm) distal to nasion
Collimated field
3 x 3 inches (8 x 8 cm)
Field should extend from the glabella to the acanthion and ½ inch beyond the tip of the nose
Note the size of the collimated field.
Should include from glabella to acanthion.

62. Lateral Nasal Bones

63. Lateral Nasal Bones

64. Lateral Nasal Bones

65. Lateral Nasal Bones
Be sure to include frontonasal suture (nasion ) and the anterior nasal spine (acanthion)
Collimate from glabella to acanthion.

66. Pathologic Indications for Facial Radiography
Fractures
Blowout
Tripod
LeFort
Coutrecoup
Foreign Body
Osteomyelitis
Neoplasms
Secondary Osteomyelitis
TMJ Syndrome
Fractures- a break in the structure of a bone caused by some sort of trauma.
Blowout fracture- is a fracture of the floor of the orbit, caused by a direct blow to the orbital region. The floor ruptures and the inferior rectus muscle is forced through the fracture into the maxillary sinuses. This often causes diplopia (perception of two images), double vision.
Tripod- is a fracture caused by a blow to the zygoma. It causes a break in 3 places- orbital process, maxillary process, and the arch. This causes a free floating zygomatic bone.
LeFort- is a fracture that is bilateral horizontal fractures of the maxillae. Results in an unstable detached fragment.
Countrecoup- is an fracture on one side of a structure caused by a blow from the other side.
Fractures are evaluated by routine radiograph projections and/or CT imaging
Foreign body of the eye- metal or other fragments in the eye. This usually occurs in an industrial setting. Evaluated by routine radiograph projections.
Neoplasms- new and abnormal growth (tumor). Can be evaluated by routine radiograph projections but also CT/MRI
Osteomyelitis- localized infection of the bone/bone marrow. This is usually a result of a trauma, fracture or postoperative bacteria. It also can be spread by blood from a distant site.
Secondary Osteomyelitis- an infection of the bone and marrow secondary to sinusitis, results in erosion of the bony margins of the sinus. (CT/MRI)
TMJ syndrome- set of symptoms that includes pain and clicking that indicates dysfunction of the TMJ’s. It can be caused by malocclusion, stress, muscle spasm, or inflammation. Evaluate by routine radiographs or by CT/MRI