Practice Letterhead

6021University Blvd., Suite #500

Ellicott City, MD21043

Phone (123)123-1234

Fax (123)123-1234

Dental CT Report

Patient Name: / Doe, John / ID Number: / 123456 / Date of Birth: / 04/04/63
Sex: / Male / Date of Exam: / 5/1/12 / Requesting Provider: / Blue Health

IAC Dental CT Sample Report1

NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility

Practice Letterhead

6021University Blvd., Suite #500

Ellicott City, MD21043

Phone (123)123-1234

Fax (123)123-1234

Diagnosis: Mandible fracture
Imaging Study Performed:Volumetric Cone-beam CT of dentoalveolar and supporting structures
Comparison Studies:No images available to compare.
CT Protocol/Scan Parameters:The Gendex i-CAT was used with the Standard Volume protocol. The patient was seated and positioned upright, with the head aligned and supported with a chin/forehead rest. VolumeCT data was acquired. Multiplanar reconstruction was performed on a viewing workstation to obtain axial and coronal images. Images were manipulated to adjust contrast for bone window viewing.
  • Scan Time: 8.9 (seconds)
  • Peak Voltage: 120 kVp
  • Tube Current: 18.5 mAs
  • Total Dose: .07 mSv
  • Maximum Slices: 600
  • Field of View: 16cm x 13cm
  • Slice Thickness: 0.3mm

Clinical History/Indications for Scan:John Doe is a 24-year-old male who previously presented to clinic with the above-mentioned diagnosis. The need for this imaging study was discussed with the patient, questions answered, and pregnancy status confirmed.
Image Quality:No motion artifact present. Patient positioning appropriate for scan type. All bony structures of the maxillofacial region were included in the exam.
Findings: Axial and coronal non-contrast bone window CT images of the maxillofacial region as well as reconstructed Tru-Pan images were reviewed. There appears to be a moderately displaced fracture of the posterior lateral left maxillary sinus with associated mucositis and opacification of the inferior sinus cavity. Infraorbital rims appear intact bilaterally. There is subcutaneous air located in the infraorbital rim that does not extend into the orbital cavity. No fracture of the nasal bones. There is a fracture of the left anterior lateral maxilla in the are of the butress that appears slightly posteriorly displaced. The mandibular condyles appear seated in the fossa. There is a fracture extending from the left mandibular sigmoid notch posteriorly to the posterior ramus approximately 3 cm inferior to the condyle. There is a right mandibular condyle fracture extending from the sigmoid notch posteriorly to the posterior ramus approximately 3cm below the condyle. Both mandibular condylar fractures are minimally displaced. There is also a minimally displaced anterior mandibular parasymphyseal fracture extending from between teeth #24 and 25 inferio-laterally to the right inferior border. This fracture has an area of comminution of the buccal cortex near the inferior border. No significant subcutaneous air in this region or mass effect on the airway.
Impression:
  1. Left ZMC fracture
  2. Left posterior lateral maxillary sinus wall fractures
  3. Subcutaneous air in the periorbital tissues that does not extend into the orbit proper
  4. Bilateral minimally displaced mandibular subcondylar fractures
  5. Minimally displaced anterior mandibular paDrrasymphyseal fracture

xxx – Interpreting Dentist/Physician (digitally or manually signed)

Date of interpretation: 4-2-12

Date of final report: 4-3-12

IAC Dental CT Sample Report1

NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility