INTRA-ORAL RADIOGRAPHIC
EXAMINATION
DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY
Intraoral radiographic examinations are the
backbone of imaging for general dentist.
It is divided into 3 categories:
Periapical Projection
Bitewing projection
Occlusal projection
GENERAL STEPS FOR MAKING AN
EXPOSURE
▪ Greet and seat the patient
▪ Adjust the x-ray unit setting
▪ Position the tube head
▪ Wash hands thoroughly
▪ Examine the oral cavity
▪ Position the film
▪ Position the x-ray tube
▪ Make the exposure
PERIAPICAL RADIOGRAPHY
Paralleling technique Bisecting angle
technique
INDICATION
1. Detection of apical infection or inflammation.
2. Assessment of periodontal status
3. After trauma to assess teeth and alveolar bone
4. Assessment of presence and position of unerupted
teeth.
5. Assessment of root morphology before extraction
6. During endodontic therapy
7. Preoperative assessment and postoperative appraisal of
apical surgery
[Link] evaluation of apical cysts and other lesion
within the alveolar bone
[Link] of position and prognosis of implants.
PARALLELING TECHNIQUE
PARALLELING TECHNIQUE
➢Also called Right-angle Or Long-cone technique.
➢The essence of this technique is that the X-ray film is
supported parallel to the long axis of teeth and the central
ray of x-ray beam is directed at right angle to the teeth and
film.
FILM-HOLDING INSTRUMENTS:
➢Use film holding instruments to position the film
properly in patient’s mouth and maintain film in
position.
➢To position the film parallel to the teeth and project
the periapical area onto the film, position the film away
from the teeth and toward the center of the mouth to
use the maximum height of the palate.
➢For maxillary projection: superior border of film
generally rest at the height of palatal vault in the
midline,
➢For mandibular projection: use the film to displace
the tongue towards the midline to allow the inferior
borde of film to rest on floor of mouth away from
mucosa on lingual surface of mandible.
Paralleling Technique
Film Selection for Adults
➢ The # 1 size film is used for anterior periapical films using
the paralleling technique. The long axis of the film is
vertical. For posterior films, # 2 size film is used with the
long axis horizontal.
#1 #2
anterior posterior
Paralleling Technique
Film Selection for Children
For children with small mouths, the # 0 size film is used
for both anterior and posterior periapical films. However,
if the child’s mouth is large enough to reasonably
accommodate the larger size films (# 1 anterior, # 2
posterior), and the child is cooperative, they should be
used.
#0 #0
anterior posterior
Paralleling Film Placement
Because the palate and floor of
the mouth are shallower as you
approach the lingual of the
teeth, the film often cannot be
positioned properly close to the
teeth.
As a result, the film must be
positioned away from the teeth
(farther back in the mouth) to
achieve parallelism.
Because the film is farther from the teeth, there will be
increased magnification (larger size) and decreased
sharpness (less detail). To compensate for this, the target-
film distance should be increased (the target is where the
x-rays are produced).
size of image at 8” target-film distance
Target
16” Target
8”
size of image at 16” target-film distance
PARALLELING TECHNIQUE
(ADVANTAGES)
1. Better dimensional accuracy: the paralleling
technique results in less distortion of the image of
the teeth. (The shape of the teeth and the
relationship of the teeth to surrounding
structures is more accurate).
2. When using the paralleling instrument with the
aiming ring, the alignment of the x-ray beam is
simplified.
3. It is easier to standardize films. Because you are
using the positioning instrument, it is easier to
position the film in approximately the same
position at different appointments. This can be
helpful if you are trying to compare the
appearance of a periapical lesion from one visit
to the next.
4. Head position is not as critical. Because of the
paralleling instrument, with its aiming ring, it is
easy to properly align the x-ray beam no matter
how the head is positioned.
DISADVANTAGES OF
PARALLELING TECHNIQUE
1-Difficult to image all parts of the mouth
2-Increased exposure time.
3-Need long cones & film holders.
4-Cannot image apical area in shallow
palate.
5-Discomfort of film holder.
6-Time consuming.
BISECTING ANGLE TECHNIQUE
➢ This technique is
based on Cieszynski’s
rule of isometry
➢ It states that two
triangles are equal
when they share one
complete side and
have two equal angles.
In the Bisecting Angle Technique, the x-ray beam is
directed perpendicular to an imaginary line which
bisects (divides in half) the angle formed by the long
axis of the tooth and the long axis of the film .
Long axis of tooth Bisecting line
X-ray beam
Long axis of film
POSITIONING OF THE PATIENT
➢Maxillary arch:
Patient’s head should be positioned upright with the
sagittal plane vertical and occlusal plane horizontal.
➢Mandibular arch:
Head is tilted back slightly to compensate for the
changed occlusal plane when mouth is opened.
Head Position
➢ When viewed from the front of the patient, the
Midsagittal Plane is perpendicular to the floor.
MSP
floor
Bisecting Angle Technique
Film Selection for Adults
The # 2 size film is routinely used for all periapical films
using the bisecting angle technique. The long axis of the
film is vertical for anterior films and horizontal for
posterior films.
#2 #2
anterior posterior
Bisecting Angle Technique
Film Selection for Children
➢ For children with small mouths, the # 0 size film is
used for both anterior and posterior periapical films.
➢ However, if the child’s mouth is large enough to
reasonably accommodate the larger size films, and the
child is cooperative, they should be used.
#0 #0
anterior posterior
ANTERIOR PERIAPICAL
➢ The # 2 (or # 0) size film is positioned vertically with the all-white
side of the film facing the teeth.
➢ The identifying dot is placed at the incisal edge of the teeth.
➢ The thumb or finger is applied to the back (colored) side of the
film at approximately the junction of the tooth with the gingiva; this
provides good support for the film and avoids film bending.
➢ The film should extend ¼” beyond the incisal edges of the teeth.
POSTERIOR PERIAPICAL
➢ The # 2 (or # 0) size film is positioned horizontally with the all-
white side of the film facing the teeth.
➢ The identifying dot is placed at the occlusal surface of the teeth.
The finger is applied to the back (colored) side of the film at
approximately the junction of the tooth with the gingiva; this
provides good support for the film and avoids film bending.
➢ The film should extend ¼” beyond the occlusal surface of the
teeth.
FILM-HOLDING INSTRUMENTS
➢Several methods
➢Prefered: film holding
instrument(snap-A-ray) or bisecting
angle instrument
BISECTING INSTRUMENT
➢ The Bisecting Angle Instrument is shown below.
➢ Notice that the bite block support, against which the film
will be aligned, is not parallel with the ring;
➢ it is slightly angled to accommodate the bisecting technique.
➢This slight tilt of the film does little to make film placement
more comfortable for the patient over the paralleling
technique; that is why finger placement is recommended if the
bisecting technique is indicated.
SNAP-A-RAY
➢ Another instrument that may be used for posterior periapical
films is the Snap-A-Ray.
➢The alligator jaws hold the film tightly and, since there is no
support behind the film, the film can flex as the patient closes.
➢This makes it more comfortable for the patient.
FINGER RETENTION
➢ The method most often used is to have the patient support the film from the
lingual surface with his or her forefinger.
➢ When using finger placement, always use the hand opposite to the side of the
mouth being radiographed. (e.g., use the left index finger when taking the right
maxillary premolar film).
➢Use either thumb for the max. incisor film, the thumb or index finger (opposite
hand) for the maxillary canines, and the index finger for all mandibular films and
for the maxillary posterior films (opposite hand).
➢Help the patient by positioning their thumb or finger
where you want them to apply pressure.
* However this method has
several drawbacks:
-- Excessive force
-- Bending of film
-- Film may slip
-- Cone cut
ANGULATION OF THE TUBE HEAD
PROJECTION MAXILLA MANDIBLE
INCISOR +40 DEGREES -15 DEGREES
CANINE +45DEGREES -20 DEGREES
PREMOLARS +30 DEGREES -10 DEGREES
MOLARS +20 DEGREES -5 DEGREES
POIN OF ENTRY
TOOTH MAXILLA MANDIBLE
INCISOR Tip of the nose At the midline & below the
lower lip
CANINE Ala of the nose In the line of ala of the nose
& above 3 cm of inferior
border of mandible
PREMOLAR Intersection of midpuppillary In the line of pupil of eye &
line with ala tragus line above 3 cm of inferior
border of mandible
MOLAR Outer canthus of eye with In the line of outer canthus
ala tragus line line & of inferior border of
mandible
VERTICAL ANGULATION
➢ The x-ray beam is directed perpendicular to the bisecting
line..
➢ Here You can see the film long axis, but you have to
“visualize” the inclination of the long axis of the tooth.
➢ Once you determine the angle, imagine the bisecting line
and direct the x-ray beam at a 90-degree angle (perpendicular)
to this line. This is the vertical angulation.
Bisecting line
Long axis of tooth
X-ray beam
Long axis of film
Vertical Angulation
➢ In the diagram below, the tooth is imagined to be more
upright than it really is.
➢As the tooth is rotated into its correct inclination , the angle
changes and the bisecting line (green dotted line) is less steep,
requiring an increased vertical angulation (green arrow).
➢Because most people imagine the tooth to be more upright
than it really is, it is recommended that 5 degrees be added to
the vertical angulation you have chosen.
HORIZONTAL ANGULATION
➢ The horizontal angulation is adjusted so that a line connecting
the front and back edge of the PID (yellow line below) is parallel
with a line connecting the buccal surfaces of the premolars and
molars (green line below). The x-rays will then be perpendicular to
the film.
correct incorrect
Bisecting Angle Technique
(Advantages)
➢ When comparing the two periapical techniques, the advantages of
the bisecting angle technique are:
1. More comfortable: because the film is placed in
the mouth at an angle to the long axis of the teeth,
the film doesn’t impinge on the tissues as much.
2. A film holder, although available, is not needed.
Patients can hold the film in position using a finger.
3. No anatomical restrictions: the film can be
angled to accommodate different anatomical
situations using this technique
Anatomical Variations
➢ Anatomical situations which might require using
the bisecting angle technique are:
• shallow palate
• Large palatal torus
• shallow or tender floor of the mouth
• short lingual frenum (tongue-tie)
Bisecting Angle Technique
(Disadvantages)
➢When comparing the two periapical techniques, the disadvantages
of the bisecting angle technique are:
1. More distortion: because the film and teeth are
at an angle to each other (not parallel) the
images will be distorted.
2. Harder to position x-ray beam: as mentioned
previously, because a film holder is often not used
it is difficult to visualize where the x-ray beam
should be directed.
3. Film less stable: using finger retention, the film
has more chance of moving during placement
SUMMARY OF COMPARISON BETWEEN SHORT-CONE &
LONG-CONE TECHNIQUE
SHORT CONE LONG-CONE
Diffusion and distortion of image. Sharp details of the image obtained.
Increased chances of elongation or shortening Image obtained is of the same size and shape
of the image. as the object.
Distorted image of the teeth due to oblique Image of the teeth nearly anatomically
exposure and bending of the film. accurate, from use of right angle exposure and
flat surface of the film.
Shadows of the alveolar bone tend to fill the Alveolar crest seen in true relationship to the
interproximal spaces. teeth.
More vertical angulation. Less vertical angulation similar buccal and
lingul parts of the teeth appear close to each
other in the radiograph, and more tooth area
underneath restorations is revealed.
Superimposition of the shadow of the Less vertical angulation in the maxillary molar
zygomatic arch on the teeth. region avoids the shadow of the zygomatic
arch and the teeth apices and maxillary sinus
are better seen.
Easier technique to maneuver and requires Needs a larger working space.
less space.
Short cone Long cone
More effective when the palate is shallow, In a similar situation apices of the teeth
children with adult size teeth but may be cut off.
underdeveloped jaws.
In rare cases when the teeth are longer This is not possible in the long cone
than film, the entire tooth may be seen, technique.
by over angulating the vertical angulation.
Cone cutting is a common error especially, The PID, helps reduce such errors.
in the maxillary third molar area.
Curved film due to incorrect finger Use of the film holding device prevents
pressure. such an error.
BITEWING RADIOGRAPHY
BITE-WING EXAMINATION
➢ Also called interproximal
radiographs.
➢ Valuable for detecting
interproximal caries in early
stages of development
before it becomes clinically
apperent.
➢ Detection of secondary caries below
restoration
➢ Also useful for evaluating the
periodontal condition.
➢ For evaluating alveolar bone crest and
changes in bone height can be assessed by
comparison with adjacent teeth.
➢ Useful for detecting calculus
deposites in interproximal
area.
PREMOLAR BITEWING
PROJECTION
IMAGE FIELD:
It should cover the distal portion of mandibular
canine anteriorly and show equally the crowns
of maxillary and mandibular teeth.
Film placement
➢ Place the film between tongue and teeth, far enough from lingual
surface of teeth to prevent interference by palate on closing and
parallel to the long axis of tooth.
➢The anterior border of film should extend beyond contact area
between mandibular canine and first premolar.
➢Hold the film in place until the patient’s mouth is completely closed.
PROJECTION OF CENTRAL RAY
➢Adjust the horizontal angulation of cone to
project the central ray to the center of the film
though the premolar contact areas.
➢ To compensate for slight inclination of film
against the palatal mucosa, the vertical
angulation should be about +5 degrees.
POINT OF ENTRY
➢ Identify the point of entry by retracting
the cheek and determining that central ray
will enter the line of occlusion at the point
of contact between second premolar and
first molar.
MOLAR BITEWING PROJECTION
IMAGE FIELD:
➢ It should show distal surface of most posterior
erupted molar and equally the crown of
maxillary and mandibular molars.
FILM PLACEMENT
➢ Place the film between tongue and teeth, as far lingual as
practical to avoid contacting the sensitive attached gingiva.
➢ The distal margin of the film should extend 1-2 mm beyond the
most posterior erupted molar.
➢ When using XCP, adjust the horizontal angulation by placing
the guide bar parallel with the direction of central ray to open the
contact area between first and second molar.
PROJECTION OF CENTRAL RAY
➢ Project the central ray to the center of film and through the
contact of first and second maxillary molars.
➢ Angle the central ray slightly from the anterior because the molar
contacts usually are not oriented at right angle to buccal surface of
these teeth.
➢ A vertical angulation of +10 degrees is recommended.
POINT OF ENTRY
➢ The central ray should enter the cheek
below the lateral canthus of the eye at
level of the occlusal plane.
OCCLUSAL RADIOGRAPHY
-- This technique is used to examine
large areas of upper and lower jaws.
-- The palate and floor of the mouth
may also be examined.
-- This is supplementry radiographic
technique that is usually used in
conjunction with periapical or
bitewing radiographs.
INDICATION
[Link] locate supernumerary , unerupted or impacted
teeth.
[Link] locate foreign body in maxilla or mandible.
[Link] locate salivary stone in duct of submandibular
glands.
[Link] locate and evaluate the extent of lesion e.g.
cyst , tumor, etc.
[Link] evaluate boundaries of maxillary sinus.
6. To evaluate fracture of mandible and maxilla.
7. To aid in examination of patient who can not open
their mouth more than few millimeters or in adult
and children Who are unable to tolerate periapical
films.
8. To examine area of cleft palate.
9. As a midline view, when using the parallex method
for determining the bucco/palatal position of
unerupted canines.
CLASSIFICATION OF OCCLUSAL
VIEWS
MAXILLARY
[Link]
[Link]-SECTIONAL
[Link]
MANDIBULAR
[Link]
[Link]-SECTIONAL
[Link]
Anterior maxillary occlusal
projection
Image field:
➢ The primary field of
this projection includes-
❖ Anterior maxilla and
its dentition
❖Anterior floor of nasal
fossa
❖Teeth from canine to
canine.
Film placement :
-- Adjustment of patient head
-- placement of film
-- stabilization of film
Projection of central ray :
-- Orientation : through
tip of nose
-- Vertical angulation:
+ 45 degree
-- Horizontal angulation:
0 degree
Cross-sectional maxillary occlusal
projection
Image field :
This projection shows :
➢ Palate
➢ Zygomatic process of maxilla
➢ Antero inferior aspect of each
antrum
➢ Naasolacrimal canals
➢ Teeth from second to second
molars
➢ Nasal septum
Film placement :
-- position of patient’s head
-- positioning of film
-- stabilizing of film
Projection of central ray :
-- Orientation : through the
bridge of the nose just
Below the nasion,
-- Vertical angulation :
+65 degrees
-- Horizontal angulation : 0 degrees
Lateral maxillary occlusal
projection
Image field :
This projection shows;
➢ Quadrant of alveolar ridge of
maxilla
➢Inferolateral aspect of antrum
➢Tuberosity
➢Teeth from lateral incisor to
contralateral 3rd molar
❖ In addition , the zygomatic
process of maxilla superimposes
over roots of molar teeth
Film placement :
-- positioning of patient
-- positioning of film
-- stabilizing the film
Projection of central ray :
-- Orientation :to a point 2 cm
below the lateral canthus
of the eye.
-- Vertical angulation :
+ 60 degrees
Anterior mandibular cross-sectional
projection
Image field :
This projection includes ;
➢ Anterior portion of mandible
➢ Dentition from canine to
canine
➢ Inferior cortical border
of mandible
Film placement :
-- positioning of patient
-- positioning of film
-- stabilizing the film
Projection of cantral
ray :
-- Orientation : -10 degree
angulation through the
point of chin towards the
middle of film.
-- This gives -55 degree of
angulation to the plane of
film.
Cross-sectional mandibular
occlusal projection
Image field :
This projection includes ;
➢ Soft tissue of floor of mouth
➢ Reveals lingual and buccal plate
from 2nd molar to 2nd molar
❖ When This view is made to
examine floor of mouth(e.g. for
sialolith), the exposure time should
be reduced to one half the time used
to creat an image of mandible.
Film placement :
-- positioning of patient
-- placement of film
Projection of central ray :
-- Through the floor of mouth
approximately 3 cm below the
chin, at right angle to the
center of film
Lateral mandibular occlusal
projection
Image field :
This projection covers ;
➢Soft tissue half of floor of mouth
➢Buccal and lingual cortical plate of half of the
mandible
➢Teeth from lateral incisor to contralateral 3rd
molar
❖ When this view is used to provide an image
of floor of mouth, the exposure time should be
reduced to one half that used to provide an
image of mandible
Film placement:
-- positioning of patient
-- positioning of film
Projection of central ray :
Orientation :direct the central
ray perpendicular to the center
of the film through a
-- point beneath the chin
-- 3 cm posterior to the point
of the chin and
-- 3 cm lateral to midline.
SPECIAL
CONSIDERATION
SPECIAL CONSIDERATION
✓INFECTION
✓TRAUMA
✓MENTALLY DISABLED PATIENT
✓PHYSICALLY DISABLED PATIENT
✓GAG REFLEX
✓RADIOGRAPHIC TECHNIQUES FOR
ENDODONTICS
✓PREGNANCY
✓EDENTULOUS PATIENT
Infection
➢ Infection in orofacial structures may result
in edema and lead to trismus of some of the
muscle of mastication.
➢ So, intraoral radiography may be painful
to the patient and difficult for both patient
and radiologist.
➢Under such circumstances,extra-oral or
occlusal radiograph may offer the only
possibilities of an examination.
➢In case of edema in an area to be
examined, increase exposure time to
compansate for the tissue swelling.
Trauma
➢ A patient suffered from trauma- dental or skeletal
fracture.
Dental fracture – periapical or occlusal radiographs.
Skeletal fractures – panoramic or other extraoral
views or CT scan.
➢ In patients with fractures of facial skeleton may be
bedridden because of involvement of other injuries –
extra oral radiographic examination in supine position
is necessory.
Mentally disabled patient
➢ Patient with mental disabilities may
cause some difficulty for radiologist.
➢ Difficulties due to,
-- patient’s lack of coordination.
-- inability to comprehend what is
expected.
➢ However , by performing radiographic
examination speedily, unpredictable move
by patient can be minimized.
➢ In some case sedation may be required.
Physically disabled patient
➢ Patient with physically disabilities
may require special handling during
radiographic examination.
➢ these patients are usually
cooperative and eager to assist.
➢ Establishment and maintainance
of good rapport between patient
and radiographic technician.
➢ Members of patient’s family often
are very helpful.
Gag reflex
➢ Occassionally, patient who need a
radiographic examination manifest a gag
reflex at slightest provocation.
➢ Such patients are very apprehensive and
frightened by unknown procedure.
➢ While others have very sensitive tissue that
stimulate gag reflex when stimulated.
➢Gag reflex worse when patient is tired.
➢Longer the film stay in mouth – greater
possibilities that patient will start to gag.
➢ Any little exercise that can be devised that doesn’t
interfere with radiographic examination but shift
patient’s attention from film and mouth is likely to
relieve gag reflex.
➢In extreme cases, application of topical anesthetic
agent to produce temporary numbness of tongue and
palate.
➢Most effective approach -
▪ Reduce apprehension
▪ Minimize tissue irritation
▪ Encourage rapid breathing through nose.
➢ If all measures fail – extraoral radiographic
examination is only means.
pregnancy
➢ Fetus is sensitive to
ionizing radiation
➢ Minimum radiographic
examination with the
mother’s dental needs.
➢ Use of optimal radiation
safety technique.
Edentulous patient
➢ Radiographic examination is very important in
edentulous patient. e.g. edentulous areas may
contain --roots, rasidual infection, impacted teeth,
cysts or other pathologic entities.
➢ Edentulous patient – older age group –
malignant tumors.
➢After determination - diseases free jaw – no
more periodic radiographs.
Radiographic techniques for edentulous patient
-- panoramic examination – more convenient.
-- If alveolar ridge deformity – high resolution intra-oral
projection.
-- Film holding device used for intra-oral alveolar ridges.
- complicated by tipping into the voids occupied by
crowns of teeth
- managed by use of , cotton rolls and orthodontic
elastic.
-- if panaromic not available – 14 intra-oral provide
excellent survey.
Radiographic technique for
endodontics
➢ Radiographs are essential to the practice of
endodontics.
➢Certain requirements must be observed:
-- the tooth being treated must be centered in
the image.
-- film must be positioned as far from tooth
and apex as the region permit to ensure that
apex of tooth and some periapical bone are
apparent on radiograph.
Projection techniques
➢ Patient positioning.
➢ Use of hemostat
➢ Specially designed
instrument for
Endodontic.(endo-ray)
Endodontic use :
➢ To separate the roots on
multirooted teeth.
➢In case of sinus tract encountered.
➢To demonstrate the quality of root
canal filling and condition of
periapical tissue.