Sei sulla pagina 1di 49

/http://dentalbooks-drbassam.blogspot.

com

Introduction
Radiography involves the use of x-radiation and thus is potentially dangerous if mishandled. For
your own sake, and that of the staff, patient, and public, it is essential that you gain adequate
knowledge of radiographic techniques and radiation health and safety, prior to performing clinical
procedures.
This course is intended to provide current, vital information on film and tube head placement, to
serve as a guide to acquire new skills or refine current skills, and allow you to test yourself as you
progress through the pages.
When you complete a continuing education course on the Dental ResourceNet, a form will come
up that requests your name, address, etc. If you are a member of the AGD, make sure to fill out
the field that asks for your AGD membership number (if you are not an AGD member, leave
blank). When you hit submit, a copy of the "proof of completion" is e-mailed directly to the AGD
and P&G. For your records, make sure to print a copy of the "proof of completion" certificate.

Overview
Radiography involves the use of x-radiation and thus is potentially dangerous if mishandled. For
your own sake, and that of the staff, patient, and public, it is essential that you gain adequate
knowledge of radiographic techniques and radiation health and safety, prior to performing clinical
procedures.
This course is intended to provide current, vital information on film and tube head placement, to
serve as a guide to acquire new skills or refine current skills, and allow you to test yourself as you
progress through the pages

Learning Objectives
Upon the completion of this course, the dental professional will be able to:

Understand the basic principles and concepts of intraoral procedures.


Demonstrate the paralleling technique of intraoral radiology.
Explain the bisecting angle technique of intraoral radiology.
Identify proper techniques for bitewing radiography.
Describe intraoral occlusal techniques.

Course Contents

Introduction
Intraoral Procedures
Paralleling Technique
Paralleling Technique Methodology
The Bisecting Angle Technique
Bisecting Angle Methodology
Bitewing Radiography
Intraoral Occlusal Radiography
Digital Radiology
Summary
Glossary
Course Test
About the Authors
1Page

Introduction
Radiography involves the use of x-radiation and thus is potentially dangerous if mishandled. For
your own sake, and that of the staff, patient, and public, it is essential that you gain adequate
knowledge of radiographic techniques and radiation health and safety, prior to performing clinical
procedures.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

This course is intended to provide current, vital information on film and tube head placement, to
serve as a guide to acquire new skills or refine current skills, and allow you to test yourself as you
progress through the pages.

Intraoral Procedures
Introduction
The intraoral radiograph, when correlated with the case history and clinical examination, is one of
the most important diagnostic aids available to the dental practitioner. When examined under
proper conditions, diagnostic-quality intraoral radiographs reveal evidence of disease that cannot
otherwise be found. They also play a major role in forensic identification.
Two of the fundamental rules of radiography are that 1) the central beam should pass through the
area to be examined, and 2) the x-ray film should be placed in position so as to record the image
with the least amount of image distortion. Each of three types of intraoral radiologic examinations
commonly used in dental practiceperiapical, bitewing (interproximal), and occlusal
examinationsdepend on the operators adherence to these two rules even though specific
techniques, processes, and indications differ widely among them.
Another aspect that these three examinations have in common pertains to the film packet. The
film packet has two sides, a tube side and a tongue side. The tube side may be plain or textured.
When placed intraorally, the tube side always faces the radiation source, the tube head. The
tongue side may be colored and has a flange to open the packet and remove the film. When
placed intraorally, the tongue side always faces the patients tongue, except in the case of the
mandibular occlusal examination.
Because of patient anatomic variations such as narrow arches, missing teeth, or the presence of
tori, and limitations of the patients ability to open sufficiently (caused by age or other factors), or
maintain the film placement, a clinical examination must precede the taking of films. After the
clinical examination, the operator can determine the number and size of films to expose, the
technique modifications necessary, and the type of film retention devices to be employed.
Advancements are continually being made in the development and manufacturing of the actual film
packet. These advancements have helped to decrease radiation exposure. Whenever possible
the "fastest" film speed should be used.
Periapical Radiographs
The purpose of the intraoral periapical examination is to obtain a view of the entire tooth and its
surrounding structures, as in Figure 1. Two exposure techniques may be employed for periapical
radiography: the paralleling technique and the bisecting angle technique. The paralleling
technique is the preferred method. This technique provides less image distortion and reduces
excess radiation to the patient. The paralleling technique should always be attempted before other
techniques. The bisecting technique can be employed for patients unable to accommodate the
positioning of the paralleling technique. Candidates may include those with low palatal vaults and
children. Disadvantages to the bisecting technique include image distortion and excess radiation
due to increased angulations involving the eye and thyroid glands. Regardless of the technique,
however, the rules of radiography referred to earlier must be followed.

2Page

Figure 1

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Intraoral Procedures
Bitewing Radiographs
2T 2T

Bitewing examinations were introduced by Raper in 1925. The greatest value of bitewing
radiographs is the detection of interproximal caries in the early stages of development, before it is
clinically apparent. The arrows in Figure 2 indicate areas of interproximal caries. Bitewing
projections also reveal the size of the pulp chamber and the relative extent to which proximal
caries have penetrated.
Bitewings also provide a useful adjunct to evaluating periodontal conditions, offer a good view of
the septal alveolar crest, and, in addition, permit changes in bone height to be accurately assessed
by comparison with adjacent teeth. Bitewings do not show the apices of the teeth and cannot be
used to diagnose in this area.

Figure 2
2T 2T

Occlusal Radiographs
2T 2T

Occlusal radiography is a supplementary radiographic examination designed to provide a more


extensive view of the maxilla and mandible (Figure 3).

Figure 3
2T 2T

The occlusal radiograph is very useful in determining the buccolingual extension of pathologic
conditions, and provides additional information as to the extent and displacement of fractures of
the mandible and maxilla. Occlusals also aid in localizing unerupted teeth, retained roots, foreign
bodies, and calculi in the submandibular and sublingual salivary glands and ducts. It should be
noted that when imaging soft tissues exposure time needs to be appropriately reduced.
Dentulous Adult Survey
2T 2T

The number of films needed for a full mouth series varies greatly. Some practitioners may prefer
10 films, while others may prefer 18, 20 or more exposures.
The selection of film sizes used in a full mouth series also varies. A full survey can consist of
narrow anterior film (size #1); standard adult film (size #2); #2 bitewing film or long bitewing film
(size #3), (Figure 4) and may include anterior bitewings. It is generally recommended to use 20
films --- four bitewings and 16 periapicals. Eight anterior #1 films will allow for ease of film
3Page

placement on patients with narrow palates. However, in some cases six anterior periapicals will
cover the area needed.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

By using #3 film only one film is used on both the right and left sides and opening both the
premolar and molar contacts on one film is very difficult. (Figure 5) With the use of #2 films for
bitewings, the operator uses a total of four films. Each film is assigned either premolars or molars.
(Figure 6) Use of the #2 films instead of #3 films for bitewings is not only more comfortable for the
patient but is easier for the operator to open the contacts.
4Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 5
2T

Figure 6
2T

Intraoral Procedures
Edentulous Adult Survey
2T 2T

By definition, an edentulous patient is one without the natural dentition, and a partially edentulous
patient is one who retains some, but not all of the natural dentition. Merely because a patients
clinical exam reveals an edentulous state does not disqualify him or her from diagnostic
radiographic examination. In fact, it is commonly accepted that certain areas of the patients jaws
may contain tooth roots or impacted teeth. Residual infection, tumors, cysts, or related pathology
may also be found, which, while not visible to the clinician, would hinder the effectiveness and
comfort of an appliance such as a denture and could potentially cause life threatening conditions to
the patient. In addition to the hidden pathology mentioned above, edentulous surveys reveal the
position of the foramina and the type of bone present.
In the case of the partially edentulous patient, placement of the film holding device may be
complicated by its tendency to tip or slip into the voids which would normally be occupied by the
crowns of the missing teeth. This can usually be overcome by placing cotton rolls between the
patients alveolar ridge and the film holder, thereby supporting the film holding device in position.
A 14 or 16 film intraoral periapical survey will usually examine the tooth bearing region in most
edentulous patients (Figure 7). Bitewings are not needed because there are no interproximal
5Page

areas to be examined.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

2T Figure 7
The use of film holders allow the paralleling technique to be used with edentulous patients. The
operator may be able to reduce radiation exposure in the edentulous patient by 25% by using the
paralleling technique. The film can be held in biteblocks to which cotton rolls have been taped. To
prevent patient discomfort on biting due to missing teeth and resultant over-closing of the arches,
the cotton rolls can be attached to the upper and lower surfaces of the biteblocks. Opposing arch
denture or partial denture appliances can be left in place to make contact with the biteblock.
The radiographic film should be positioned with approximately one-third of the films vertical
dimension protruding beyond the alveolar ridge; that is, the radiographic image should occupy two-
thirds of the film. The horizontal angulation of the central beam is perpendicular to the film in the
horizontal plane. If bisecting, the vertical angulation of the central beam is much increased for an
edentulous patient with minimal ridges. The film placement may be similar to that of an occlusal
film, and this flat film placement is the principal cause of dimensional distortion. To determine
vertical angulation it is necessary to estimate the long axis of the ridge instead of the tooth.

Intraoral Procedures
Mixed Dentition Survey
The full mouth survey for pediatric patients may vary, depending on the patients age, eruption
pattern, behavior, and the size of the childs mouth. In the six to nine-year-old group, a 12 film
survey, using #1 narrow film is recommended, and would include:

Maxillary:
o Central incisors
o Right and left lateral incisors and canines
o Right and left primary/permanent molars
Mandibular:
o Central incisors
o Right and left lateral incisors and canines
o Right and left primary/permanent molars
Bitewings:
o Right and left primary/permanent molars

An adult-sized periapical film is used in the posterior region if the childs first permanent molar is
fully developed. The size of the tooth requires the use of a large periapical film to capture the
complete image.
Pre-School Child Survey
Since pre-school children have smaller mouths, reduced size pediatric films (film size #0) are used
6Page

to examine the posterior teeth, and adult films are used for anterior examinations in children who
have only primary (deciduous or "baby") teeth. For this group, an eight film survey is
recommended.

Maxillary:
o Central incisors
o Right and left primary molars
Mandibular:

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

o Central incisors
o Right and left primary molars
Bitewings:
o Right and left primary molars

The paralleling technique should be used whenever possible. This technique delivers the lowest
dose of radiation possible. The bisecting angle technique is a viable alternative for pediatric
radiography because the apices of the permanent molar teeth tend to lie above the palate and
below the floor of the mouth in the undeveloped mandible. These positions prevent the image of
the apices of the teeth from being projected into the oral cavity when the x-ray beam is
perpendicular to the long axis of the teeth as it is when using the paralleling technique.

Quiz

1. What should be done before any radiographic examination?


2. What are the fundamental rules of radiography?
3. What is the purpose of the intraoral periapical examination?
4. What are the two primary techniques used in periapical radiography?
5. What is the primary purpose of bitewing radiographs?
6. What else can be accurately assessed with bitewings?
7. List five indications for taking occlusal radiographs.
8. What sizes of periapical films are commonly used in a dentulous adult survey?
9. Why should a radiographic examination be performed for a clinically edentulous patient?
10. How should film be positioned relative to the alveolar ridge?

Answers

1. A good clinical examination should be carried out before every radiographic examination.
2. The central beam should pass through the area to be examined and the x-ray film should be
placed in position to record the image with the least amount of distortion.
3. To obtain a view of the entire tooth and surrounding structures.
4. Paralleling and bisecting angle technique.
5. The detection of caries in the early stages of development.
6. The detection of periodontal disease in the early stages.
7. Detection of pathological lesions; fractures of the mandible and maxilla; foreign bodies; salivary
calculi; localizing unerupted teeth.
8. Number 1, 2 and 3 film.
9. It is commonly accepted that certain areas in the jaws may contain roots, impacted teeth,
residual infections, tumors, cysts, etc.
10. The film should be placed with approximately one-third of the vertical dimension protruding
beyond the alveolar ridge.

Paralleling Technique
Basic Principles
2T 2T

The paralleling technique of intraoral radiography was developed by Gordon M. Fitzgerald, and is
so named because the object (tooth), receptor (film packet), and end of the position indicating
device (PID) are all kept on parallel planes. Its basis lies in the principle that image sharpness is
primarily affected by focal-film distance (distance from the focal spot within the tube head and the
film), object-film distance, motion, and the effective size of the focal spot of the x-ray tube.
Successfully using the paralleling technique depends largely on maintaining certain essential
conditions as illustrated in Figure 8. These are: 1) the film packet should be flat; 2) the film packet
must be positioned parallel to the long axis of the teeth; and 3) the central ray of the x-ray beam
must be kept perpendicular to the teeth and film.
7Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

2TFigure 8
To achieve parallelism between the film and tooth (i.e., to avoid bending or angling the film) there
must be space between the object and film. However, remember that as the object-to-film
distance increases, the image magnification or distortion also increases. To compensate,
manufacturers are recessing the target (focal spot) into the back of the tube head. Depending on
the machine's age, and placement of the focal spot within the tube head, you may encounter long,
medium, or short cones/PIDs. The goal is to have the focal spot at least 12" or 30 cm from the film
to reduce image distortion.
The anatomic configuration of the oral cavity determines the distance needed between film and
object and varies among individuals. However, even under difficult conditions, a diagnostic quality
radiograph can be obtained provided that the film packet is not more than 20 degrees out of
parallel with the tooth, and that the face of the PID/cone is exactly parallel to the film packet to
produce a central beam which is perpendicular to the long axis of the tooth and the film packet.
The major advantage of the paralleling technique, when done correctly, is that the image formed
on the film will have both linear and dimensional accuracy. The major disadvantages are the
difficulty in placing the film packet and the relative discomfort the patient must endure as a result of
the film holding devices used to maintain parallelism. The latter is particularly acute in patients
with small mouths and in children. In certain circumstances the film and holder may be slightly
tipped toward the palate to accommodate oral space and patient comfort. Too much palatal
tipping will throw off all parallel planes.

Paralleling Technique
Beam Angulation
The position of the x-ray tube head is usually adjusted in two directions: vertically and horizontally.
The vertical plane is adjusted by moving the tube head up and down. The horizontal plane is
adjusted by moving the tube head from side to side. By convention, deflecting the head so that it
points downward is described as positive vertical angulation or + vertical. Correspondingly, an
upward deflection is referred to as negative vertical angulation or - vertical (Figure 9). The degree
of vertical angulation is usually described in terms of plus or minus degrees as measured by a dial
on the side of the tube head.
8Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 9
When applying the paralleling technique, the vertical angulation is ALWAYS dictated to
maintaining the parallel plane. There is no set degree number to follow. As stated earlier under
basic principles, the object (tooth), receptor (film packet), and end of the position indicating device
(PID) are all kept on parallel planes. If the vertical angulation is excessive the image will appear
foreshortened. Insufficient vertical angulation procedures an elongated image.
The beams horizontal direction determines the degree of overlap among the tooth images at the
interproximal spaces. If the beam is not perpendicular to the specific interproximal space(s) as it
approaches several relatively aligned objects, the objects overlap and the space(s) between them
close. Imagine a flashlight beam approaching a picket fence perpendicularly at a 90-degree
angle. The spaces between the pickets will remain open in the shadow image unless the beam
angle varies from perpendicular or 90 degrees. The degree of overlapping of the image will
increase or decrease as the beam angle increases or decreases from the perpendicular.
Film Holding Devices
The paralleling technique requires the use of film holding devices to maintain the relatively precise
positioning needed. A great variety of film holders are commercially availablesimple, complex,
light, heavy, reusable, disposable, autoclavable, and non-autoclavable. A few of the more
common include XCP (extension cone paralleling) with localizing rings, Snap-a-ray, Precision
rectangular paralleling device, Uni-Bite, and Stabe biteblock (Figure 10 and 11). Having several
options available will provide the operator different opportunities for enhanced patient comfort. It is
not uncommon to employ more than one option during the same radiographic survey.

Figure 10
9Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 11
The dental radiographer should be able to assess which holder best conforms to the technical and
diagnostic requirements of the job, the needs of the patient, and infection control protocols within
the office.

(Table 1: Paralleling - Exposure Guide and Film Placement - Helpful hints when utilizing
Stabe or Snap-a-ray film holders)

Paralleling - Exposure Guide and Film Placement


U

Helpful hints when utilizing Stabe or Snap-a-ray film holders

BITEWINGS Teeth to include C.R. Entry Point Vertical. Angulation


+ 10 (down angle of
R Molar BWX #1, 2, 3, 30, 31, 32 & D. of 4 & 29 contact of #2 & #3
PID)
R Premolar BWX #4, 5, 28, 29 & D. of 6 and 27 contact of #4 & #5 + 10 (down)
D. of #11 and 22, and #12, 13, 20,
L Premolar BWX contact of #12 & #13 + 10 (down)
21
D. of #13 and 20, 14, 15, 16, 17,
L Molar BWX contact of #14 & 15 + 10 (down)
18, 19

* * * * *

imaginary plane can be visualized on the face to offer approximate C.R. placement. For Maxillary exposures, imagine the plane to extend between the
a of the nose and the tragus of the ear (a.k.a. the ala-tragus line.) For Mandibular exposures, imagine this plane to extend between the commissure of
e mouth and the tragus of the ear (a.k.a. the commissure-tragus line.) Once this plane is established, the following entry points will be a guide for C.R.
acement. Approximate vertical angulations are only guides and must be checked for paralleling before exposure as each persons anatomy is different.

Approx. C.R. Entry


PERIAPICALS Teeth to include Approx. Vert. Ang.
Point
outer canthus of the
UR Molars #1, 2, half of #3 +20 - +30 (down)
eye
UR Premolars M. of #3, 4, 5, and half of #6 pupil of the eye +30 - + 40 (down)
UR Canine center #6 c.r. at D. of 6 ala of the nose +45 - + 55 (down)
10Page

Max. Incisors center #7, 8, 9, 10 (I.U. method) tip of the nose +40 - +50 (down)
UL Canine center #11 c.r. at D. of 11 ala of the nose +45 - + 55 (down)
UL Premolars half of #11, and 12, 13, M. of 14 pupil of the eye +30 - + 40 (down)
outer canthus of the
UL Molars half of #14, and 15, 16 +20 - +30 (down)
eye

LL Molars #17, 18, and half of 19 outer canthus of the - 5 0 (up angle of

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

eye PID)
LL Premolars M. of #19, and 20, 21, and half of 22 pupil of the eye -10 - -15 (up)
LL Canine center #22 c.r. at D. of 22 ala of the nose -20 - -30 (up)
Mand. Incisors center #23, 24, 25, 26 (I.U. method) cup the chin -15 - -25 (up)
LR Canine center #27 c.r. at D. 27 ala of the nose -20 - -30 (up)
half of #27, and 28, 29 and M. of
LR Premolars pupil of the eye -10 - -15 (up)
#30
outer canthus of the
LR Molars half of #30, and 31, 32 - 5 0 (up)
eye
e of: Willie Leeuw, CDA, BS - Indiana University Purdue University Fort Wayne , Department of Dental Assisting

Quiz

1. What is the basic principle of the paralleling technique?


2. What is the major advantage of the paralleling technique?
3. What are the major disadvantages?
4. What must be done to achieve parallelism between the tooth and film?
5. List several devices available to position the film properly when using the paralleling
technique.

Answers

1. The film packet must be positioned parallel to the long axis of the teeth and the x-ray beam
must be kept perpendicular to the teeth and film.
2. Linear and dimensional accuracy.
3. Difficulty in placement of the film packet, relative discomfort to the patient caused by film
holding devices.
4. The film must be placed away from the tooth.
5. XCP with localizing rings, Snap-a-ray, Precision rectangular devices, Uni-Bite, and Stabe
biteblock.

Paralleling Technique Methodology


When taking a full mouth survey, a definite order of exposure should be preplanned and then
followed. Since patients tolerate anterior films better, they should be done first. Starting with the
maxillary central incisors and proceeding distally, first along one side, then the other, is
recommended. The radiographic parameters or exposure factors should also be determined prior
to placing films in the patients mouth.
Patient Positioning
2T 2T

When positioning a patient, there are two imaginary planes that must be considered. The occlusal
plane runs horizontally, dividing the patients head into upper and lower portions. It can be
visualized by imagining the patient holding a ruler between his or her teeth. A midsagittal plane
divides a mass (the patients head or body) on a vertical dimension into equal right and left
portions.
When using the paralleling technique to examine the maxillary region, the patient is positioned so
that the occlusal plane of the maxilla is parallel to the floor and the sagittal plane of the patients
head is perpendicular to the floor.
When paralleling the mandibular region, the patients position must be modified slightly so that
when the mouth is open, the mandible is parallel to the floor and the sagittal plane is
perpendicular. This could mean that the patient must be tilted back in the chair.
Before any radiographs are exposed, the patient must be protected with a lead apron and thyroid
11Page

collar. The apron must be properly placed to avoid interference with the radiographic exposure.
(Figure 12)

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 12
2T

Paralleling Technique Methodology


Full Mouth Exposure with the Use of XCP Device
Procedure for the Maxillary Central/Lateral Incisors

1. Assemble the anterior film holder and insert the film packet vertically on the anterior
biteblock. Use a #1 film.
2. Center the film on the central/lateral incisors (Figure 13). Position the film in the palate as
posteriorly as possible so that the entire tooth length will appear on the film, with
approximately a one-eighth inch border of the film extending below the incisal edge of the
centrals. Position the biteblock on the incisal edges of the teeth to be radiographed
(Figure 14). Proper positioning in this step will place the central ray of the x-ray beam at
the interproximal contact desired.
12Page

Figure 13 Figure 14

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

3. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 15).
5. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

Figure 15

Paralleling Technique Methodology


Full Mouth Exposure with the Use of XCP Device
Procedure for the Maxillary Canines

1. Assemble the anterior film holder and insert the film packet vertically on the anterior
biteblock. Use a #1 film.
2. Center the film on the canine and first premolar (Figure 16). Position the film in the palate
as posteriorly as possible so that the entire tooth length will appear on the film with
approximately a one-eighth inch border below the incisal edge of the canine. Position the
13Page

biteblock on the incisal edges of the teeth to be radiographed (Figure 17). Proper
positioning in this step will place the central ray of the x-ray beam at the interproximal
contact desired.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 16 Figure 17

3.
4. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
5. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 18).
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

14Page

Figure 18
Procedure for the Maxillary Premolars

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

1. Assemble the posterior film holder and insert the film packet horizontally in the posterior
biteblock. Use a #2 film.
2. Center the film on the premolars so that it is parallel to the long axis of the teeth (Figure
19). Position the film in the palate so that the entire tooth length will appear on the film
with approximately a one-eighth inch border below the cuspal ridge. Align the anterior
edge of the film packet with the canine so that the image captured on the anterior border
of the film will include the distal third of the canine. Position the biteblock on the occlusal
surfaces of the teeth to be radiographed (Figure 20). Proper positioning in this step will
place the central ray of the x-ray beam at the interproximal contact desired.

Figure 19 Figure 20

3.
4. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
(The occlusal border of the film tends to slip lingually.)
5. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 21).
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

15Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 21

Paralleling Technique Methodology


Full Mouth Exposure with the Use of XCP Device
Procedure for the Maxillary Molar Region

1. Assemble the posterior film holder and insert the film packet horizontally in the posterior
biteblock. Use a #2 film.
2. Center the film on the molars so that it is parallel to the long axis of the teeth (Figure 22).
Position the film in the palate so that the entire tooth length will appear on the film with
approximately a one-eighth inch border below the cuspal ridge. Align the anterior border
of the film packet with the second premolar so that the image captured on the anterior
edge of the film will be the distal third of the second premolar. Position the biteblock on
the occlusal surfaces of the teeth to be radiographed (Figure 23). Proper positioning in
this step will place the central ray of the x-ray beam at the interproximal contact desired.
16Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 22 Figure 23

3.
4. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
5. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 24).
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

17Page

Figure 24
Procedure for the Mandibular Central/Lateral Incisors

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

1. Assemble the anterior film holder and insert the film packet vertically on the anterior
biteblock. Use a #1 film.
2. Center the film on the mandibular central and lateral incisors (Figure 25). It may be
necessary to displace the tongue distally and depress the film onto the floor of the mouth
so that the entire tooth length will show with approximately a one-eighth inch border above
the incisal edges. The film must be as posterior as the anatomy allows and the biteblock
should be positioned on the edges of the incisors to be radiographed (Figure 26). Proper
positioning in this step will place the central ray of the x-ray beam at the interproximal
contact desired.

Figure 25 Figure 26

3.
4. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
The film should be straightened as the patient closes and the floor of the mouth relaxes.
5. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 27).
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

18Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 27

Paralleling Technique Methodology


Full Mouth Exposure with the Use of XCP Device
Procedure for the Mandibular Canines

1. Assemble the anterior film holder and insert the film packet vertically on the anterior
biteblock. Use a #1 film.
2. Center the film on the mandibular canine (Figure 28). It may be necessary to displace the
tongue distally and depress the film onto the floor of the mouth so that the entire tooth
length will show with approximately a one-eighth inch border above the cuspal edge. The
film must be as posterior as the anatomy allows and the biteblock should be positioned on
the edges of the teeth to be radiographed (Figure 29). Proper positioning in this step will
place the central ray of the x-ray beam at the interproximal contact desired.
19Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 28 Figure 29

3.
4. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
The film should be straightened as the patient closes and the floor of the mouth relaxes.
5. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 30).
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

20Page

Figure 30
Procedure for the Mandibular Premolars

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

1. Assemble the posterior film holder and insert the film packet horizontally on the posterior
biteblock. Use a #2 film.
2. Center the film on the premolars so that it is parallel to the long axis of the teeth (Figure
31). The object-to-film distance in both the mandibular premolar and molar regions is
minimal since the oral anatomy only allows the film to be positioned very close to the teeth
and still remain parallel. Align the anterior border of the film packet with the canine so that
the image captured on the anterior edge of the film will be the distal third of the canine.
Position the biteblock on the occlusal surfaces of the teeth to be radiographed (Figure
32). Proper positioning in this step will place the central ray of the x-ray beam at the
interproximal contact desired.

Figure 31 Figure 32

3.
4. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
The film should be straightened as the patient closes and the floor of the mouth relaxes.
5. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 33).
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

21Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 33

Paralleling Technique Methodology


Full Mouth Exposure with the Use of XCP Device
Procedure for the Mandibular Molars

1. Assemble the posterior film holder and insert the film packet horizontally on the posterior
biteblock. Use a #2 film.
2. Center the film on the molars so that it is parallel to the long axis of the teeth (Figure 34).
Depress the film onto the floor of the mouth so the entire length of the teeth will appear
with approximately a one-eighth inch border above the occlusal surface. Place the film
horizontally and position it lingually to the molars so that the long axis of the film is parallel
to the long axis of the tooth. Align the anterior border of the film packet with the second
premolar so that the image captured on the anterior edge of the film will be the distal third
of the second premolar. Position the biteblock on the occlusal surfaces of the mandibular
teeth (Figure 35). Proper positioning in this step will place the central ray of the x-ray
beam at the interproximal contact desired.
22Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 34 Figure 35

3.
4. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
The film should be straightened as the patient closes and the floor of the mouth relaxes.
5. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close
to the aiming ring, and center (Figure 36).
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

23Page

Figure 36

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Quiz

1. What is the recommended patient positioning for examining the maxillary region using the
paralleling technique?
2. What is the recommended patient positioning for examining the mandibular region using
the paralleling technique?

Answers

1. The occlusal plane of the maxilla is parallel to the floor and the sagittal plane of the patients
head is perpendicular to the floor.
2. When the mouth is open, the mandibular occlusal plane is parallel to the floor and the sagittal
plane of the patients head is perpendicular to the floor.

The Bisecting Angle Technique


Basic Principles
The bisecting-the-angle or bisecting angle technique is based on the principle of aiming the central
ray of the x-ray beam at right angles to an imaginary line which bisects the angle formed by the
longitudinal axis of the tooth and the plane of the film packet. While it is not necessary to go into a
long dissertation on plane geometry to understand this concept, a quick review will help make the
technique more clear. To bisect is to divide a line or angle into two equal portions. A bisector is a
plane or line that divides a line or angle into two equal portions. Figure 37 shows an equilateral
triangle, with legs AB=BC=CA, and the angles ABC=60 degrees, CAB=60 degrees and BCA=60
degrees.

Figure 37
We see in Figure 37 the following:
24Page

1. The dotted line BD bisects the triangle, dividing it exactly in half. Thus, two equal triangles
are formed from the original. Legs AB and BC were unchanged and thus are still equal.
2. The original line CA was divided in half by D, and thus the lines AD and CD are equal.
3. We know that the angle at point B was 60 degrees, and since it was bisected (divided
equally), it now is 30 degrees at the intersections of AD and BD.
4. We also know that bisecting the angle did not affect the angle at the old point A which was
60 degrees, and still is.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

5. The angle at the bisecting point DC must be 90 degrees because the sum of all the angles
in any triangle is 180 degrees, and thus 180-(60+30)=90.
6. Cyzynskis Rule of Isometry states that two triangles are equal when they share one
complete side, and have two equal angles. We can see that triangles ADB and BDC
share the common side BD.
7. We know further that the angles ADB and BDC are equal because D was defined as a
bisector of the old angle ABC.
8. Lastly, we know that the angles CAB and BCA were unchanged by bisecting and are still
equal. Therefore, under Cyzynskis Theorem, we can prove the triangles ABD and CBD
are equal.

In dental radiography, the theorem is applied in the following manner. The film is positioned
resting on the palate or on the floor of the mouth as close to the lingual tooth surfaces as possible.
The plane of the film and the long (vertical) axis of the teeth to be radiographed form an angle with
the apex at the point where the film packet contacts the teeth. The apex in Figure 38 is located at
the point labeled B.
In Figure 38, the long axis through the tooth forms one leg of a triangle (AB), the plane of the film
packet another leg, (BC), both of which intersect at the apex, point B. A line representing the
central x-ray beam will form the third leg of the triangle, AC. If an imaginary line bisected this axis-
packet-ray triangle, the bisector, DB, would form the common side of two equal triangles as
defined by Cyzynskis Theorem.

Figure 38
Since the sides formed by the tooths long axis and the film packet are equal, the image cast onto
the radiographic film would be the same length as the tooth or teeth casting that image. This linear
equality is the basis for diagnostic quality bisecting angle radiographs.

The Bisecting Angle Technique


Anatomical Considerations
The bisecting angle technique is of value when the paralleling technique cannot be utilized. This
may include patients with small mouths and those with low palatal vaults. Because of the
increased exposure to radiation in this technique, it should only be employed as necessary.
Beam Angulation
The bisecting technique calls for varying beam angulations, depending on the region to be
examined.
Horizontal angulation: The horizontal angulation of the tube head should be adjusted for each
projection to position the central ray through the contacts in the region to be examined. This
angulation will usually be at right angles to the buccal surfaces of the teeth to be radiographed.
25Page

Vertical angulation: In practice, the operator should position the central ray of the x-ray beam so
that it is perpendicular to the imaginary line bisecting the angle formed between the tooth long axis
and the film. This principle works well with flat, two-dimensional structures, but teeth that have
depth or are multirooted will produce distorted images. If the vertical angulation is excessive the
image will appear foreshortened. Insufficient vertical angulation produces an elongated image.
The optimum angle will vary from patient to patient, but the chart below serves as a general
guideline for beam angulation.
Projection Maxilla Mandible

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Incisors +40 degrees -15 degrees


Canine +45 degrees -20 degrees
Premolar +30 degrees -10 degrees
Molar +20 degrees 2-5 degrees
Film Holding Devices
Supporting the film pack with the patients forefinger is not recommended. This method has
several drawbacks. In addition to exposing the patients digit to additional radiation, the patient
may exert excessive force, thus bending the film and distorting the radiograph. The film may slip
without the operators knowledge, and produce a radiograph outside the proper image field.
Therefore, intraoral support is best accomplished using instruments that restrain the film and help
align the beam properly.

Quiz

1. On what principle is the bisecting angle technique based?


2. How did this principle originate?

Answers

1. The bisecting angle technique is based on the principle of aiming the central ray of the x-ray
beam at right angles to an imaginary plane bisecting the angle formed by the longitudinal axis
of the tooth and the plane of the film packet.
2. The principle originated from Cyzynskis Rule of Isometry (Cyzynskis Theorem) which states
that two triangles are equal when they share one complete side and have two equal angles.

Bisecting Angle Methodology


Patient Positioning
Maxillary region: For bisecting angle radiographs of the maxilla, the patient should be positioned
so that the maxillary occlusal plane is parallel to the floor and the sagittal plane of the patients
head is perpendicular to the floor.
Mandibular region: For bisecting angle radiographs of the mandible, the patient should be
positioned so that the mandibular occlusal plane is parallel to the floor and the sagittal plane of the
patients head is perpendicular to the floor.
Before any radiographs are exposed, the patient must be protected with a lead apron and thyroid
collar. The apron must be properly placed to avoid interference with the radiographic exposure.
Full Mouth Exposure
Procedure for the Maxillary Central/Lateral Incisors

1. Assemble the anterior film holder and insert the film packet vertically on the biteblock.
Use a #1 film.
2. Center the film on the central/lateral incisors as close as possible to the lingual surfaces of
the teeth with approximately a one-eighth inch border of the film extending below the
incisal edge of the centrals (Figure 39). Position the biteblock on the incisal edges of the
teeth to be radiographed (Figure 40).
26Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 39 Figure 40

3.
4. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
5. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should bisect the
central/lateral (Figure 41). For maxillary exposures the tube head will be pointed down for
positive (+) angulation.
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

27Page

Figure 41

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Bisecting Angle Methodology


Full Mouth Exposure
Procedure for the Maxillary Canines

1. Assemble the anterior film holder and insert the film packet vertically on the biteblock.
Use a #1 film.
2. Center the film on the canine as close as possible to the lingual surfaces of the teeth with
approximately a one-eighth inch border of the film extending below the incisal edge of the
centrals (Figure 42). Position the biteblock on the incisal edges of the teeth to be
radiographed (Figure 43).

Figure 42 Figure 43

3.
4. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
5. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should bisect the canine
(Figure 44). For maxillary exposures the tube head will be pointed down for positive (+)
angulation.
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

28Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 44
Procedure for the Maxillary Premolars

1. Assemble the posterior film holder and insert the film packet horizontally on the biteblock.
Use a #2 film.
2. Center the film on the premolars as close as possible to the lingual surfaces of the teeth
(Figure 45). Position the film in the palate so that the entire tooth length will appear on the
film with approximately a one-eighth inch border below the cuspal ridge. Align the anterior
border of the film packet with the canine so that the image captured on the anterior edge
of the film will be the distal third of the canine. Position the biteblock on the occlusal
surface of the teeth being radiographed (Figure 46).

29Page

Figure 45 Figure 46

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

3.
4. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
(Watch the occlusal border of the film packet; it tends to slip down anteriorly.)
5. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should pass between the
contact of the first and second premolar (Figure 47). For maxillary exposures the tube
head will be pointed down for positive (+) angulation.
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

Figure 47

Bisecting Angle Methodology


Full Mouth Exposure
Procedure for the Maxillary Molars

1. Assemble the posterior film holder and insert the film packet horizontally on the biteblock.
Use a #2 film.
2. Center the film on the molars as close as possible to the lingual surfaces of the teeth
30Page

(Figure 48). Position the film in the palate so that the entire tooth length will appear on the
film with approximately a one-eighth inch border below the cuspal ridge. Align the anterior
border of the film packet with the second premolar so that the image captured on the
anterior edge of the film is the distal third of the second premolar. Position the biteblock
on the occlusal surface of the teeth being radiographed (Figure 49).

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 48 Figure 49

3.
4. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
5. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should pass between the
contact of the first and second molar (Figure 50). For maxillary exposures the tube head
will be pointed down for positive (+) angulation.
6. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

31Page

Figure 50

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Procedure for the Mandibular Central/Lateral Incisors

1. Assemble the anterior film holder and insert the film packet vertically on the biteblock.
Use a #1 film.
2. Center the film on the central/lateral incisors as close as possible to the lingual surfaces of
the teeth with approximately a one-eighth inch border of the film extending above the
incisal edge of the centrals. Position the biteblock on the incisal edges of the teeth to be
radiographed (Figure 51).

Figure 51

3. A cotton roll may be inserted between the maxillary incisors and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
The film should be straightened as the patient closes and the floor of the mouth relaxes.
4. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should pass between the
central/lateral incisors (Figure 52). For mandibular exposures the tube head will be
pointed up for negative (-) angulation.
5. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

32Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 52

Bisecting Angle Methodology


Full Mouth Exposure
Procedure for the Mandibular Canines

1. Assemble the anterior film holder and insert the film packet vertically on the biteblock. Use
a #1 film.
2. Center the film on the canine as close as possible to the lingual surfaces of the teeth with
approximately a one-eighth inch border of the film extending above the incisal edge of the
canine. Position the biteblock on the incisal edges of the teeth to be radiographed (Figure
53).
33Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 53

3. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film
position. The film should be straightened as the patient closes and the floor of the mouth
relaxes.
4. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should bisect the canine
(Figure 54). For mandibular exposures the tube head will be pointed up for negative (-)
angulation.
5. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

34Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 54
Procedure for the Mandibular Premolars

1. Assemble the posterior film holder and insert the film packet horizontally on the
biteblock. Use a #2 film.
2. Center the film on the premolars as close as possible to the lingual surfaces of the
teeth. Align the anterior border of the film packet with the canine so that the image
captured on the anterior edge of the film will be the distal third of the canine. Position the
biteblock on the occlusal surface of the teeth to be radiographed (Figure 55).

35Page

Figure 55

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

3. A cotton roll may be inserted between the maxillary premolars and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film
position. The film should be straightened as the patient closes and the floor of the mouth
relaxes.
4. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should pass between the
first and second premolars (Figure 56). For mandibular exposures the tube head will be
pointed up for negative (-) angulation.
5. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

Figure 56

Bisecting Angle Methodology


Full Mouth Exposure
Procedure for the Mandibular Molars

1. Assemble the posterior film holder and insert the film packet horizontally on the biteblock.
Use a #2 film.
2. Center the film on the molars as close as possible to the lingual surfaces of the teeth.
Align the anterior border of the film packet with the second premolar so that the image
36Page

captured on the anterior edge of the film will be the distal third of the second premolar.
Position the biteblock on the occlusal surface of the teeth to be radiographed (Figure 57).

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 57

3. A cotton roll may be inserted between the maxillary molars and the biteblock for patient
comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
The film should be straightened as the patient closes and the floor of the mouth relaxes.
4. Align the central ray perpendicular to the bisector vertically and at the desired
interproximal contact to be viewed. Horizontally, the central ray should pass between the
contact of the first and second molar (Figure 58). For mandibular exposures the tube head
will be pointed up for negative (-) angulation.
5. Follow the film and equipment manufacturers recommendation concerning exposure
factors. Make the exposure.

37Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 58

Bitewing Radiography
Bitewing radiographs are of particular value in detecting interproximal caries in the early stages of
development, before it is clinically apparent. For this reason it is critical that horizontal angulation
be accurately projected following the direction of the interproximal contacts and no overlapping
contacts be present on the film. Bitewing films are also useful in evaluation of the alveolar crests
for detection of early periodontal disease.
Basic Principles
Bitewing radiographs are parallel films because the film is positioned parallel to the long axis of the
teeth and the beam is perpendicular to the film as in Figure 59. A bitewing tab is utilized to
stabilize the film as the patient bites together (Figure 60).
38Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 59 Figure 60
Beam Angulation and Film Holding Devices
Bitewing radiographs are usually exposed with an indicated vertical angulation of +10 degrees
(tube head points down for positive (+) angulation). This, angulation provides an acceptable
compromise for the differences between the long axis inclinations of the maxillary and mandibular
teeth. Horizontal angulation is aligned with the direction of the contact, and the central ray is
directed between the contact of the teeth to be radiographed. Horizontal angulation is achieved
when the central ray of the x-ray beam is directed specifically between the contacts of the teeth to
be radiographed.
The interproximal examination may be done using special #3 bitewing film but is preferably
achieved by using #2 films fitted with a tab. There are also film holding devices available that
support the film as well as provide an external reference for positioning the tube head. The patient
stabilizes the film by gently biting together on the manufactured tab or on the instrument.
Tube head position is illustrated in Figure 61, and a sample set of bitewing radiographs is
illustrated in Figure 62.
Before any radiographs are exposed, the patient must be protected with a lead apron and thyroid
collar. The apron must be properly placed to avoid interference with the radiographic exposure.

Figure 61
39Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 62

Quiz

1. What is the main purpose for taking bitewing radiographs?


2. Why are bitewings exposed with a vertical angulation of +10 degrees?

Answers

1. To detect interproximal caries.


2. To compromise for the differences in the long axis angulations of the maxillary and mandibular
teeth.

Intraoral Occlusal Radiography


Maxillary Topographical Occlusal
2T 2T

This projection (Figure 63) shows the palate (roof of the mouth), zygomatic process of the maxilla
(a projection from the maxilla), antero-inferior aspects of each antrum (in this case, the maxillary
sinuses), nasolacrimal canals (tear ducts), teeth from the left second molars to the central incisors,
and the nasal septum (cartilage dividing the nose).

40Page

Figure 63
2T

Uses: To view the maxilla for anterior alveolar fractures, cysts, supernumerary teeth and
1T 1T

impacted canines, and to view pathology at the apices of the incisors. It is not used to diagnose
peridontal conditions.
Patient positioning: The patient is seated with the sagittal plane perpendicular to the floor and
1T 1T

the occlusal plane parallel to the floor. Before any radiographs are exposed, the patient must be

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

protected with a lead apron and thyroid collar. The apron must be properly placed to avoid
interference with the radiographic exposure.
Film placement: With the tube side of the film (size #4) toward the maxilla, the film is placed
1T 1T

crosswise in the mouth, like a sandwich. It is gently pushed backwards until it contacts the anterior
border of the mandibular ramus. The patient bites down gently to maintain position.
Exposure factors: Follow the recommendations of the film and equipment manufacturer.
1T 1T

Direction of the central ray: The central ray is directed at the center of the film with a vertical
1T 1T

angulation of +65 degrees and a horizontal angulation of 0 degrees. In this case, the central ray
will pass through the bridge of the nose, as in Figure 64.

Figure 64
2T

Mandibular Topographical Occlusal


2T 2T

Uses: To view the anterior portion of the mandible for fractures, cysts, root tip and periapical
1T 1T

pathology. It provides a very good view of the symphysis region of the mandible. (Figure 65)

41Page

Figure 65
2T

Patient positioning: The patient is seated with the head tilting slightly backward, so that the
1T 1T

occlusal plane (ala-tragus line) is 45 degrees above the horizontal plane. Before any radiographs
are exposed, the patient must be protected with a lead apron and thyroid collar. The apron must
be properly placed to avoid interference with the radiographic exposure.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Film placement: With the tube side of the film (size #4) toward the mandible, the film is placed
1T 1T

crosswise in the mouth, like a sandwich. It is gently pushed backwards until it contacts the anterior
border of the mandibular ramus. The patient bites down gently to maintain position.
Exposure factors: Follow the recommendations of the film and equipment manufacturer.
1T 1T

Direction of the central ray: The central ray is directed between the apices of the mandibular
1T 1T

central incisors and the tube is angled at -55 degrees relative to the film plane, as in Figure 66.

Figure 66
2T

Intraoral Occlusal Radiography


Maxillary Vertex Occlusal
Uses: To view the buccopalatal relationships of unerupted teeth in the dental arch. (Figure 67)

Figure 67
Patient positioning: The patient is seated with the sagittal plane perpendicular to the floor and
the occlusal plane parallel to the floor. Before any radiographs are exposed, the patient must be
protected with a lead apron and thyroid collar. The apron must be properly placed to avoid
42Page

interference with the radiographic exposure.


Film placement: The film (size #4) is placed in the same manner as the Maxillary Topographical
Occlusal.
Exposure factors: Follow the recommendations of the film and equipment manufacturer.
Direction of the central ray: The central ray is directed through the top of the skull (hence the
name vertex occlusal). Since the beam must penetrate a considerable amount of bone and soft
tissue, the exposure time must be increased. The central ray is perpendicular to the film plane and
is directed to the center of the film as in Figure 68.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 68
Mandibular Cross-Sectional Occlusal
Uses: To view the entire mandible for fractures, foreign bodies, root tips, salivary calculi, tori, etc.
(Figure 69)

Figure 69
Patient positioning: The patients head may be in any comfortable position that allows the
central ray to be directed perpendicular to the plane of the film packet. Before any radiographs are
exposed, the patient must be protected with a lead apron and thyroid collar. The apron must be
properly placed to avoid interference with the radiographic exposure.
Film placement: The film (size #4) is placed in the same manner as the Mandibular
Topographical Occlusal.
Exposure factors: Follow the recommendations of the film and equipment manufacturer.
Direction of the central ray: The central ray is perpendicular to the film plane and is directed to
the center of the film as in Figure 70.
43Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 70

Intraoral Occlusal Radiography


Posterior Oblique Maxillary Occlusal
2T 2T

Uses: To view the maxillary posterior region and provide a topographical view of the maxillary
1T 1T

sinus. The projection may be used in place of periapical films in patients who have a tendency to
gag and for examining periapical pathology and root tips. (Figure 71)

2TFigure 71
Patient positioning: The patient is seated with the occlusal plane parallel to the floor and the
1T 1T

sagittal plane perpendicular to the floor. Before any radiographs are exposed, the patient must be
protected with a lead apron and thyroid collar. The apron must be properly placed to avoid
interference with the radiographic exposure.
Film placement: The film (size #4) plane should be parallel to the floor, and the packet should be
44Page

1T 1T

pushed posteriorly as far as possible. The lateral border of the film should be positioned parallel to
the buccal surfaces of the posterior teeth and extend laterally approximately one-half inch past the
buccal cusps on the side of interest. The patient should bite down gently to maintain film position.
Exposure factors: Follow the recommendations of the film and equipment manufacturer.
1T 1T

Direction of the central ray: The tube is directed at right angles to the curve of the arch, and
1T 1T

strikes the center of the film packet as in Figure 72.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 72
2T

Posterior Oblique Mandibular Occlusal


2T 2T

Uses: The projection is used to view the posterior teeth of the mandible to locate cysts, fractures,
1T 1T

supernumerary teeth, and periapical pathology. It can be used in place of posterior periapical
films. (Figure 73)

Figure 73
2T

Patient positioning: The patient is seated with the occlusal plane parallel to the floor and the
1T 1T

sagittal plane perpendicular to the floor. Before any radiographs are exposed, the patient must be
protected with a lead apron and thyroid collar. The apron must be properly placed to avoid
interference with the radiographic exposure.
Film placement: The film (size #4) plane should be parallel to the floor, and the packet should be
1T 1T

pushed posteriorly as far as possible. The lateral border of the film should be positioned parallel to
the buccal surfaces of the posterior teeth and extend laterally approximately one-half inch past the
buccal cusps on the side of interest. The patient should bite down gently to maintain film position.
45Page

Exposure factors: Follow the recommendations of the film and equipment manufacturer.
1T 1T

Direction of the central ray: The tube is directed at the apex of the mandibular second premolar,
1T 1T

and the central ray should strike the center of the film packet. The vertical angulation is -50
degrees as in Figure 74.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 74
2T

Intraoral Occlusal Radiography


Modified Oblique Posterior Mandibular Occlusal
2T 2T

Uses: This projection is especially useful to detect calculi in the submandibular gland. Calculi are
1T 1T

often difficult to detect on conventional radiographs due to superimposition of the mandibular bone.
(Figure 75)

Figure 75
2T

Patient positioning and film placement: With the tube side of the film (size #4) toward the
1T 1T

mandible the film is placed in the patients mouth crosswise like a sandwich. The film plane should
be parallel to the floor, and the packet should be pushed posteriorly as far as possible. The lateral
border of the film should be positioned parallel to the buccal surfaces of the posterior teeth and
46Page

extend laterally approximately one-half inch past the buccal cusps on the side of interest. The
patients head is then rotated to the side and lifted up. Before any radiographs are exposed, the
patient must be protected with a lead apron and thyroid collar. The apron must be properly placed
to avoid interference with the radiographic exposure.
Exposure factors: Follow the recommendations of the film and equipment manufacturer.
1T 1T

Direction of the central ray: The tube is positioned under and behind the mandible and the
1T 1T

central ray is directed onto the center of the film so that it passes inside the ascending ramus so
that the submandibular gland will be between the tube and the film as in Figure 76.

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 76
2T

Digital Radiology
Digital imaging was introduced into dentistry in 1987. Digital sensors are used instead of x-ray film.
Sensors can be wired or wireless depending on the system used. (Figures 77 and 78) Sensors
and tube head placement are the same for digital imaging as film and tube head placement is for
traditional radiology. Most standard radiographic machines can be converted to acquire digital
images. Digital imaging still uses ionizing radiation, and therefore, before any radiographs are
exposed, the patient must be protected with a lead apron and thyroid collar. The apron must be
properly placed to avoid interference with the radiographic exposure.
The sensors are slightly thicker than a regular film. Modified film holders must be utilized in the
placement of the sensors. These modified holders can be purchased from any major dental supply
company. The sensors can be reused several times. Proper use of intraoral barrier and OSHA
techniques must be observed.
The advantages of digital radiology are decreased exposure time to the patient, elimination of
darkroom processing time and exposure to processing chemicals, immediate viewing, and ability
to easily and cost effectively transmit directly to third party facilities or affiliating dental offices.
Additional computerized advantages include the ability to enhance the image for viewing. Once an
image is in the computer, brightness and contrast and image reversal can be enhanced for optimal
viewing of tissue and bone levels. The radiograph can be rotated and magnified to enhance
details. An additional feature shows embossed images creating a stacked effect of the oral tissues.
The main disadvantages are substantial start up costs including machinery and operatory
computer technology, and compatibility with other software program and RAM capacity.
Considerations must also be noted that although your office may utilize digital radiography, other
facilities may not and the transfer of images between them could be more difficult.
47Page

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Figure 77 Figure 78

Summary
Proper film and tube head placement are a critical component of the total radiographic procedure.
Periapical, bitewing, and occlusal surveys are critical components of diagnosis and treatment of
dental patients. Because of the exposure to ionizing radiation, proper techniques must be
employed to reduce radiation exposure to the patient through the use of lead aprons, high speed
film, and proper technique; thus decreasing additional film retakes. As technology advances in
dental radiology operators must maintain current knowledge and adapt their abilities for the best
treatment of the patient.

Glossary
Alveolar Crest highest part of the alveolar bone
2T 2T

Alveolar Ridge part of the bone that contains the tooth sockets
2T 2T

Anterior in front
2T 2T

Apices plural for apex or tip of root


2T 2T

Bisector a straight line that bisects an angle


2T 2T

Buccal towards the cheek


2T 2T

Calculi plural of calculus; a hard rough deposit on the tooth surface


2T 2T

Digit finger or toe


2T 2T

Distal tooth surface away from the midline


2T 2T

Edentulous without teeth


2T 2T

Foramina plural for foramen; an opening


2T 2T

Horizontal line extending from side to side


2T 2T

Impacted trapped below the surface as in an impacted third molar


2T 2T

Incisal Edge biting surface of front teeth


2T 2T

Interproximal between the teeth


48Page

2T 2T

Intraoral inside the oral cavity


2T 2T

Lingually towards the tongue


2T 2T

Mandible lower jaw


2T 2T

Mandibular Ramus portion of the mandible that extends back and up


2T 2T

Maxilla upper jaw


2T 2T

Mesial tooth surface towards the midline


2T 2T

Occlusal biting surface of back teeth


2T 2T

Palatal pertaining to the roof of the mouth


2T 2T

Parallel extending in the same direction and same distance apart


2T 2T

http://dentalbooks-drbassam.blogspot.com/
/http://dentalbooks-drbassam.blogspot.com

Periapical surrounding the apex or tip of the tooth


2T 2T

Periodontal surrounding the tooth


2T 2T

Periodontal disease disease of the gums and supporting areas of the teeth
2T 2T

Perpendicular intersecting at a right angle


2T 2T

Posteriorly behind
2T 2T

Sagittal Plane vertical plane dividing the body


2T 2T

Supernumerary teeth extra teeth


2T 2T

Tori hard bony projections


2T 2T

Vertical line extending from top to bottom (up and down)


2T 2T

smile4Dr

49Page

http://dentalbooks-drbassam.blogspot.com/