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Intraoral Radiography

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Presentation on theme: "Intraoral Radiography"— Presentation transcript:

1 Intraoral Radiography
Chapter 41 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

2 Chapter 41 Lesson 41.1 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

3 Learning Objectives Pronounce, define, and spell the Key Terms.
Explain the advantages and disadvantages of the paralleling and bisecting techniques. Name the two primary types of projections used in an intraoral technique and describe the differences. Explain the basic principle of the paralleling technique. State the five basic rules of the paralleling technique. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

4 Learning Objectives (Cont’d) Explain why a film holder is necessary with the paralleling technique. Describe how to prepare a patient for dental x-rays. Expose a full series of radiographs using the paralleling technique. Label and identify the parts of the Rinn XCP (extension-cone paralleling) instruments. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

5 Introduction It is possible for every dental assistant to successfully produce quality dental radiographs—radiographs that are free from distortion, with the correct density and contrast, that can be used in the detection of dental disease. You can create such radiographs by carefully following the proper steps in film placement, exposure, and processing. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5

6 Fig. 41-1 Steps to quality radiographs.
What are radiographs used to detect? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6

7 Full-Mouth Survey No dental examination is complete without dental radiographs, and in almost all cases the full-mouth survey is the most preferred technique. An intraoral full-mouth examination (FMX) contains both periapical and bite-wing radiographs. The dentist cannot see beneath the gum tissue. Radiograph is used to detect disease, foreign objects, and retained roots. What are periapical radiographs? What are bite-wing radiographs? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

8 The FMX An intraoral FMX is composed of both periapical and bite-wing projections. This technique requires the use of intraoral film, which is placed inside the mouth and is used to examine the teeth and supporting structures. In the average adult, a full-mouth series consists of 18 to 20 films. Generally there are 14 periapicals and 4 to 6 bite-wings, but the number may vary. The selection of film size is important. How many sizes are available for intraoral film? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

9 Fig Mounted full-mouth series with eight anterior films, taken with the use of the parallel technique. How many periapicals are shown? How many bite-wings are shown? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

10 The Bite-Wing Radiograph
The bite-wing radiograph shows the upper and lower teeth in occlusion. Only the crowns and a small portion of the root of the teeth are seen. It is used for to detect interproximal decay, periodontal disease, and recurrent decay under restorations and to assess the fit of metallic fillings or crowns. Should show the crestal bone. Why would the crestal bone be important to see in a bite-wing radiograph? Why are these unnecessary on edentulous patients? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

11 Fig. 41-2 Bite-wing radiograph
Fig Bite-wing radiograph. Note that only the crowns and alveolar ridge, not the roots, are visible. Which teeth are the focus of this radiograph? What are those “white spots”? Can you see the pulp chamber and pulpal canal? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

12 The Periapical Radiograph
The periapical radiograph shows the entire tooth from occlusal surface or incisal edge to 2 to 3 mm beyond the apex to show the periapical bone. The periapical is used to diagnose pathologic conditions of the tooth, root, and bone, as well as tooth formation and eruption. Periapical views are essential in endodontic and oral surgery procedures. What size film would be used for an adult? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

13 Fig. 41-3 A, Anterior periapical.
Which teeth are the focus of this radiograph? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

14 Fig. 41-3 B, Posterior periapical
Fig B, Posterior periapical. Note that the entire tooth and surrounding bone are visible in the radiograph. Which teeth are the focus of this radiograph? Locate the sinus cavity. Identify the tooth impaction. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

15 Introduction to Techniques
There are two basic techniques for obtaining periapical radiographs: Paralleling Bisection of the angle The American Academy of Oral and Maxillofacial Radiology and the American Association of Dental Schools recommend the use of the paralleling technique because it provides the most accurate image. In some situations the operator may have to use the bisection technique. The operator bases the choice of technique on the patient’s needs. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

16 The Paralleling Technique: Basic Rules
Film placement: Position the film so that it will cover the teeth. Film position: Position the film parallel to the long axis of the tooth. The film in the film holder must be placed away from the teeth and toward the middle of the mouth. Vertical angulation: Direct the central ray of the x-ray beam perpendicular to the film and the long axis of the tooth. Horizontal angulation: Direct the central ray of the x-ray beam through the contact areas between the teeth. Central ray: Center the x-ray beam on the film to ensure that all areas of the film are exposed. Rules must be followed for accurate radiographs to be obtained. Why are accurate radiographs so important? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16

17 Tips for Film Placement
The white side of the film always faces the teeth. Anterior films are always placed vertically. Posterior films are always placed horizontally. The identification dot on the film is always placed in the slot of the film holder (“dot in the slot”). Always position the film holder away from the teeth and toward the middle of the mouth. Always center the film over the areas to be examined. Always place the film parallel to the long axis of the teeth. Radiographs may not be of diagnostic quality if these tips are not followed. Why do you want to avoid retakes? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17

18 Fig Position of the film, teeth, position-indicator device (PID), and central ray of the x-ray beam in the paralleling technique. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) What does the term parallel mean? What does the term perpendicular mean? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18

19 Fig The x-rays pass through the contact areas of the premolars because the central ray is directed through the contacts and perpendicular to the film. If the central ray (CR) is not directed through the contacts, overlap of the premolar contacts occurs. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) The goal is to be able to see the contact areas without overlapping. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19

20 Fig This radiograph demonstrates a cone cut— that is, a clear exposed area on the film. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) Why did this cone cut occur? How can you correct this error? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20

21 Preparation Before Seating the Patient
Prepare the operatory with all infection-control barriers. Determine the number and type of films to be exposed. Label a paper cup with the patient's name and the date. This is the transfer cup for storing and moving exposed films. Turn on the x-ray machine and check the basic settings. Wash and dry your hands. Dispense the desired number of films and store them outside the room in which the x-ray machine is being used. Where would barriers be placed in the x-ray operatory? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21

22 Positioning the Patient
Seat the patient comfortably in the dental chair, with the back in an upright position and the head supported. Ask the patient to remove eyeglasses and bulky earrings. Have the patient take any removable prosthetic appliances out of his or her mouth. Position the patient with the occlusal plane of the jaw being radiographed parallel to the floor when the mouth is in the open position. Drape the patient with a lead apron and thyroid collar. Wash and dry your hands and put on clean examination gloves. The midsagittal plane should be perpendicular to the floor. Where is the midsagittal plane? Should tongue rings or studs be removed? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22

23 The Exposure Sequence When exposing radiographs, establish an exposure sequence, or definite order, for periapical film placement. Without an exposure sequence, there is a good chance that you will omit an area or expose the same area twice. How many periapicals are taken in a full-mouth series? How many bite-wings are taken in a full-mouth series? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23

24 The Anterior Exposure Sequence
When exposing periapical films with the paralleling technique, always start with the anterior teeth (canines and incisors), because: The size 1 film used for anteriors is small, less uncomfortable, and easier for the patient to tolerate. It is easier for the patient to become accustomed to the anterior film holder. The anterior film placements are less likely to cause the patient to gag. (Cont’d) If size 1 films are used, seven or eight films are taken. What views are taken? If size 2 films are used, six films are taken. What views are taken? Always ask the dentist what size film to use and how many anterior films to take. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24

25 The Anterior Exposure Sequence
(Cont’d) Begin with the maxillary right canine (tooth 6). Expose all of the maxillary anterior teeth from right to left. End with the maxillary left canine (tooth 11). Next, move to the mandibular arch. Begin with the mandibular left canine (tooth 22). Expose all of the mandibular anterior teeth from left to right. Finish with the mandibular right canine (tooth 27). Is it OK to start on the left and work to the right? Stick to a sequence—do not change from patient to patient. Make this sequence a habit for all radiographic exposures. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25

26 The Maxillary Canine Region
Insert the number 1 film packet vertically into the anterior bite-block. Position the film packet with the canine and first premolar centered. Position the film as far to the posterior as possible. With the film-holding instrument and film in place, instruct the patient to close his or her mouth slowly but firmly. Position the localizing ring and PID, then expose the film. Have the PID close to the patient so positioning of the ring will be quick. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26

27 Maxillary Central/Lateral Incisor Region
Insert the number 1 film packet vertically into the anterior bite-block. Center the film packet between the central and lateral incisors and position the film as far to the posterior as possible. With the film-holding instrument and film in place, instruct the patient to close his or mouth slowly but firmly. Position the localizing ring and PID, then expose the film. Remind the patient to hold still during exposure. Move swiftly; remove the extension-cone paralleling device (XCP) as soon as possible from the oral cavity. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27

28 The Mandibular Canine Region
Insert the number 1 film packet vertically into the anterior bite-block. Center the film on the canine. Position the film as far in the lingual direction as the patient’s anatomy will allow. A cotton roll may be placed between the maxillary teeth and bite-block to prevent rocking of the bite-block on the canine tip and to increase patient comfort. Why is it important to have the PID close to the patient so that positioning on the ring will be quick? What other size of film could be used? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28

29 The Mandibular Canine Region
Why is it important to remove the XCP as soon as possible from the oral cavity? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29

30 The Mandibular Incisor Region
Insert the number 1 film packet vertically into the anterior bite-block. Center the film packet between the central and lateral incisors and position the film as far in the lingual direction as the patient's anatomy will allow. With the instrument and film in place, instruct the patient to close his or her mouth slowly but firmly. Position the localizing ring and PID, then expose the film. What other size of film can be used? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30

31 Mandibular Incisor Region
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31

32 The Posterior Exposure Sequence
After completing the anterior teeth, begin the posterior teeth. Always expose the premolar film before the molar film because: Premolar film placement is easier for the patient to tolerate than molar film placement. Premolar exposure is less likely to evoke the gag reflex. What size of film is used for posterior periapicals? How many premolar films will be taken in an FMX? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32

33 The Maxillary Premolar Region
Insert the film packet horizontally into the posterior bite-block, pushing the film packet all the way into the slot. Center the film packet on the second premolar. Position the film in the midpalate area. With the instrument and film in place, instruct the patient to close his or her mouth slowly but firmly. Position the localizing ring and PID, then expose the film. Remind the patient not to open his or her mouth during the exposure. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33

34 The Maxillary Premolar Region
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34

35 The Maxillary Molar Region
Insert the film packet horizontally into the posterior bite-block. Center the film packet on the second molar. Position the film in the midpalate area. With the instrument and film in place, instruct the patient to close his or her mouth slowly but firmly. Position the localizing ring and PID, then expose the radiograph. As you move more posterior in the oral cavity, remind the patient to breathe through his or her nose (to avoid gagging). What size of film is used for this area? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35

36 The Maxillary Molar Region
Where is the identification dot placed? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36

37 The Mandibular Premolar Region
Insert the number 2 film horizontally into the posterior bite-block. Center the film on the contact point between the second premolar and first molar. Position the film as far in the lingual direction as the patient's anatomy will allow. With the instrument and film in place, instruct the patient to close his or her mouth slowly but firmly. Slide the localizing ring down the indicator rod to the patient's skin. Position the localizing ring and PID, then expose the film. Remind the patient to not open his or her mouth during the exposure and to breathe through the nose. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37

38 The Mandibular Premolar Region
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38

39 The Mandibular Molar Region
Insert the number 2 film horizontally into the posterior bite-block. Center the film on the second molar. Position the film as far in the lingual direction as the tongue will allow. This position will be closer to the teeth than that for the premolar and anterior views. With the instrument and film in place, instruct the patient to close his or her mouth slowly but firmly. Position the localizing ring and PID, then expose the film. What should the dental assistant do if the patient begins gagging? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39

40 The Mandibular Molar Region
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40

41 Chapter 41 Lesson 41.2 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41

42 Learning Objectives Explain the procedural principles of the bisecting technique. Identify the types of film holders that can be used with the bisecting technique. Describe the appearance of opened and overlapped contact areas on a dental radiograph. Describe the correct vertical angulation. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42

43 Learning Objectives Describe incorrect vertical angulation.
(Cont’d) Describe incorrect vertical angulation. Identify the film size used in the bisecting technique. Expose a full series of radiographs using the bisecting angle technique. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 43

44 The Bisecting Technique
The bisection of the angle technique is based on a geometric principle of bisecting a triangle (bisecting means dividing into two equal parts). The angle formed by the long axis of the teeth and the film is bisected, and the x-ray beam is directed perpendicular to the bisecting line. “Perpendicular” means at a right angle to the film. Also known as the BAI (bisecting-angle instrument) or short-cone technique. What is the long axis of the tooth? Used as an alternative to the paralleling technique. Why would we use this method? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 44

45 Fig A, A diagram of an anterior tooth with the central ray perpendicular to the “imaginary” bisector of the angle between the long axis of the tooth and the film plane. B, A posterior tooth using the bisecting-angle concept. (From Miles D, et al: Radiographic imaging for dental auxiliaries, ed 3, Philadelphia, 1999, Saunders.) Unlike paralleling, in which the film is placed away from the teeth, the bisecting angle places the film directly against the teeth. One disadvantage of this approach is that the images may be distorted. A B Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 45

46 Film Holders Although you may see operators asking patients to hold the film with their fingers to stabilize the film in the mouth, it is not recommended. This practice exposes the patient’s hand and finger to unnecessary radiation. The following are types of commercial film holders that are available: Rinn BAI Rinn Eezee-Grip Film Holder (Snap-A-Ray) Rinn Stabe Bite-Block BAIs include a metal indicator arm, plastic bite-blocks, and plastic aiming rings. The Eezee-Grip is the easiest to use with experience, and it is more comfortable for patient. The Stabe Bite-Block is disposable. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 46

47 PID Angulations: Bisecting Technique
In the bisecting technique, the angulation of the PID is critical. Angulation is a term used to describe the alignment of the central ray of the x-ray beam in the horizontal and vertical planes. Angulation can be changed by moving the PID in either a horizontal or vertical direction. BAIs with aiming rings dictate the proper PID angulation. What is the major disadvantage of the bisecting technique? During the learning stages of this technique, BAIs will be used. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 47

48 Horizontal Angulation
Horizontal angulation refers to the positioning of the tubehead and direction of the central ray in a horizontal, or side-to-side, plane. The horizontal angulation remains the same whether you are using the paralleling or bisecting technique. What is the correct horizontal placement? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 48

49 Fig. 41-15 The arrows indicate movement in a horizontal direction.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 49

50 Correct Horizontal Angulation
With correct horizontal angulation, the central ray is directed perpendicular to the curvature of the arch and through the contact areas of the teeth. Incorrect horizontal angulation results in overlapped (unopened) contact areas. A film with overlapped contact areas cannot be used to examine the interproximal areas of the teeth. Retakes are necessary if there are overlapped contact areas. Why are retakes discouraged? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 50

51 Fig. 41-16 Correct horizontal angulation
Fig Correct horizontal angulation. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) The x-ray beam is directed perpendicular to the film. The open end of the PID is aligned parallel to the film. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 51

52 Fig. 41-17 Incorrect horizontal angulation
Fig Incorrect horizontal angulation. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) What will the x-ray show if the horizontal angulation is incorrect? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 52

53 Fig. 41-18 Overlapped contact areas.
What are contact areas? Why are they important in making a diagnosis and choosing a treatment? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 53

54 Vertical Angulation Vertical angulation refers to the positioning of the PID in a vertical, or up-and-down, plane. The vertical angulation differs depending on the radiographic technique being used: With the paralleling technique, the vertical angulation of the central ray is directed perpendicular to the film and the long axis of the tooth. With the bisecting technique, the vertical angulation is determined by the imaginary bisector; the central ray is directed perpendicular to the imaginary bisector. Measurement of vertical angulation is marked on the outside of the tubehead. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 54

55 Fig Vertical angulation of the PID refers to PID placement in an up-and-down (head-to-toe) direction. When the open end of the PID is pointing downward, the PID has positive angulation. When the open end of the PID is pointing upward, the PID has negative angulation. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 55

56 Correct Vertical Angulation
Correct vertical angulation results in a radiographic image that is the same length as the tooth. Incorrect vertical angulation results in an image that is not the same length as the tooth being radiographed. The image appears longer or shorter: Elongated Foreshortened What does the term elongation mean? What does the term foreshortening mean? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 56

57 Fig A, If the vertical angulation is to too steep, the image on the film is shorter than the actual tooth. B, Foreshortened images. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) Foreshortening occurs when vertical angulation is excessive. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 57

58 Fig A, If the vertical angulation is to too flat, the image on the film is longer than the actual tooth. B, Elongated images. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) A B Elongation occurs when vertical angulation is insufficient . Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 58

59 Film Size and Placement
In the bisection technique, the film is placed close to the crowns of the teeth to be radiographed and extends at an angle into the palate or floor of the mouth. The film packet should extend beyond the incisal or occlusal aspect of the teeth by about 1/8 to 1/4 inch. Film holders for the bisection of the angle technique, including some with alignment indicators, are available commercially. What types of film holders are available for the bisecting-angle technique? What size of film should be used for an adult? Where is the identification dot on the film placed? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 59

60 Beam Alignment The x-ray beam is directed to pass between the contacts of the teeth being radiographed in the horizontal dimension, just as it does in the paralleling technique. The vertical angle, however, must be directed at a 90-degree angle to the imaginary bisecting line. Too much vertical angulation will produce images that are foreshortened. Too little vertical angulation will result in images that are elongated. The beam must be centered to help prevent cone cutting. Recommended vertical angulation: Maxillary Canines: +45 to +55; Maxillary Incisors: +40 to +50 Maxillary Premolars: +30 to +40; Maxillary Molars: +20 to +30 Mandibular Canines: -20 to -30; Mandibular Incisors: -15 to -25 Mandibular Premolars: -10 to -15; Mandibular Molars: -5 to 0 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 60

61 Maxillary Canine Exposure
What is the proper vertical angulation used for this film? Have the PID close to the patient so positioning on the ring will be quick. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 61

62 Maxillary Incisor Exposure
What is the proper vertical angulation for this film? Remind patient to not open his or her mouth during the exposure. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 62

63 Mandibular Canine Exposure
What is the proper vertical angulation for this film? Remember that all patients are different. You will have to adjust for each one. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 63

64 Mandibular Incisor Exposure
What is the proper vertical angulation for this film? Remind the patient to breathe through the nose. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 64

65 Maxillary Premolar Exposure
What is the proper vertical angulation for this film? How will you know if you have the proper alignment? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 65

66 Maxillary Molar Exposure (Patient photo from Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) What is the proper vertical angulation for this film? How do you keep the patient from moving during this procedure? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 66

67 Mandibular Premolar Exposure (Patient photo from Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) What is the proper vertical angulation for this film? Remind the patient not to move during exposure. How much time does it take to get a complete set of radiographs? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 67

68 Mandibular Molar Exposure (Patient photo from Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) What is the proper vertical angulation for this film? Why do you begin with the radiographs that are most comfortable for the patient? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 68

69 Chapter 41 Lesson 41.3 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 69

70 Learning Objectives Explain the basic rules for the bite-wing technique. Explain the recommended vertical angulation for all bite-wing exposures. Expose and mount a series of bite-wing radiographs. Explain the technique for exposing occlusal radiographs. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 70

71 Learning Objectives (Cont’d) Expose a maxillary and mandibular occlusal radiograph. Describe techniques for managing patients with physical and mental disabilities. Describe techniques for managing the patient with a hypersensitive gag reflex. Mount and label a full series of dental radiographs. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 71

72 Bite-Wing Examinations
A bite-wing radiograph shows the crowns and interproximal areas of the maxillary and mandibular teeth and the areas of crestal bone on one film. Bite-wing radiographs are used to detect interproximal caries (tooth decay) and are particularly useful in detecting early carious lesions that are not clinically evident. Bite-wing radiographs are also useful in examining the crestal bone levels between the teeth. How many bite-wings are taken in an adult? How many bite-wings are taken in a 5-year-old child? How many bite-wings are taken in an edentulous patient? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 72

73 Basic Principles of the Bite-Wing Technique
The film is placed in the mouth parallel to the crowns of both the upper and lower teeth. The film is stabilized when the patient bites on the bite-wing tab or bite-wing film holder. The central ray of the x-ray beam is directed through the contacts of the teeth, using a +10-degree vertical angulation. What is the proper horizontal angulation for bite-wings? If the proper horizontal angulation is correct, what will be avoided? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 73

74 Fig Vertical angulation of +10 degrees is used to compensate for the slight bend of the upper portion of the film and the tilt of the maxillary teeth. (From Iannucci J, Jansen Howerton L: Dental radiography: principles and techniques, ed 3, St Louis, 2006, Saunders.) The bite-wing tab stabilizes the film in the mouth when the patient bites down. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 74

75 Fig. 41-23 Bite-wing tab and film holder.
This photo depicts a bite-wing loop. The bite-wing loop is also available in sticky tabs. It has the advantage of being reusable for all four bite-wings in an adult. Bite-wing tabs are discarded after each patient. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 75

76 Bite-Wing Film Placement
The film is positioned (with either a bite tab or a film-holding device) parallel to the crowns of both upper and lower teeth, and the central ray is directed perpendicular to the film. The premolar bite-wing radiograph should include the distal half of the crowns of the canines, both premolars, and often the first molars on both the maxillary and mandibular arches. The molar bite-wing should be centered over the second molars. The bite-wing tab or loop should be centered on the film before placement. Premolar films are taken first because they are less likely to trigger the gag reflex. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 76

77 Premolar bite-wing. A, Film placement. B, Resultant radiograph.
Be sure that the patient’s occlusal plane is parallel to the floor; adjust as needed. Placement guideline: The most mesial portion of the film should be aligned with the center of the mandibular canine. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 77

78 Molar bite-wing. A, Film placement. B, Resultant radiograph.
Remind the patient to remain still and to not move the film with his or her tongue. Placement guideline: Position the identification dot toward the occlusal surface on all bite-wings. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 78

79 The Occlusal Technique
The occlusal technique is used to examine large areas of the upper or lower jaw. In the occlusal technique, size 4 intraoral film is used. The film is so named because the patient bites, or “occludes,” on the entire film. In adults, size 4 film is used in the occlusal examination. In children, size 2 film can be used. Used to locate: Retained roots Supernumerary teeth Salivary stones Fractures Cleft palate Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 79

80 Basic Principles of the Occlusal Technique
The film is positioned with the white side facing the arch exposed. The film is placed in the mouth between the occlusal surfaces of the maxillary and mandibular teeth. The film is stabilized when the patient gently bites on the surface of the film. Will the patient need to wear a lead apron for this type of film? Will the patient need to remove dentures, partials, or retainers? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 80

81 A, The central ray (CR) is directed at an angle of +65 degrees to the plane of the film. B, Relationship of film and PID. +65° Be sure that the occlusal plane is parallel to the floor. The patient should be in an upright position. The patient should bite down gently–otherwise the film may be damaged. A B Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 81

82 Patients with Special Needs
Radiographic examination techniques must often be modified to accommodate patients with special needs. The dental radiographer must be competent in altering radiographic technique to meet the specific diagnostic need of the individual patient. Do not ask any unnecessary personal questions regarding a patient’s special needs. Be compassionate. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 82

83 Physical Disabilities
A person with a physical disability may have problems with vision, hearing, or mobility. You must make every effort to meet the individual needs of such patients. In many cases, a family member or caretaker accompanies the person with a physical disability to the dental office. You can ask the caretaker to assist you in communicating with regard to the physical needs of the patient. Use terminology that can be understood by patient, but avoid “baby talk.” Mobility: Ask whether the patient needs your assistance. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 83

84 Fig. 41-24 Wheelchair-bound patient having x-rays taken.
Talk to the patient, not to the patient’s caregiver. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 84

85 Patients with Special Dental Needs
Reasons for radiographs in the edentulous patient: To detect the presence of root tips, impacted teeth, and lesions (cysts, tumors). To identify objects embedded in bone. To observe the quantity and quality of bone that is present. What does the term edentulous mean? What are root tips? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 85

86 Exposure Techniques for the Edentulous Patient
The radiographic examination of an edentulous patient may include a panoramic radiograph, periapical radiographs, or a combination of occlusal and periapical radiographs. Radiographic images must be made in all teeth-bearing areas of the mouth, whether or not teeth are present. In edentulous patients, either bisection of the angle or the paralleling technique may be used. Because there are no teeth present, the distortion inherent in the bisecting technique does not interfere with the diagnostic intrabony conditions. In partially edentulous patients, cotton rolls can be used to stabilize the film-holding devices. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 86

87 Fig. 41-25 Mixed occlusal-periapical edentulous survey.
What size of film is used for periapicals? What size of film is used for occlusals? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 87

88 Radiographs in the Pediatric Patient
In children, radiographs are useful in detecting conditions of the teeth and bones, in showing changes related to caries and trauma, and in evaluating growth and development. Explain the radiographic procedures you are about to perform in terms that the child can easily understand. For example, you can refer to the tubehead as a camera, the lead apron as a coat, and the radiograph as a picture. Exposure factors (milliamperage, kilovoltage, time) must be reduced because of the smaller size of the pediatric patient. Avoid “baby talk.” Use positive reinforcement with children. Always commend the child on a job well done. It’s important to move quickly; have all settings ready and remind child to hold still. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 88

89 Fig XCP instruments can also be used for the pediatric patient, but the exposure time is reduced. What sizes of film are used for children? Demonstrate actions for the child before you begin. You may need to postpone films if the child is uncooperative. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 89

90 Radiographs for the Endodontic Patient
It often is difficult to obtain accurate radiographs during endodontic (root canal) treatment because of the rubber dam clamp, endodontic instruments, or filling material extending from the tooth. The Endoray II film holder can be used to aid in positioning the film during this portion of the root canal procedure. This holder fits around a rubber dam clamp and allows space for endodontic instruments and filling materials to protrude from the tooth. Periapical film must be positioned to see 5 mm past the apex of the tooth. The tooth should be centered on the film. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 90

91 Fig. 41-27 Endoray II film holder.
What does this film holder resemble? Extension near film is to protect the materials used for endodontic procedure. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 91

92 The Patient Who Gags To help prevent the gag reflex, you must convey a confident attitude. In a patient with a hypersensitive gag reflex, you should expose the maxillary molars last. When you place films in the maxillary posterior, do not slide them along the palate. There may be times when you will encounter a patient with an uncontrollable gag reflex. When this occurs, you must use extraoral radiographs such as panoramic or lateral jaw radiographs. Do not ask the patient whether he or she is a “gagger.” Remind the patient to breathe through the nose. Commend the patient on a job well done. Move quickly; remove films immediately from the mouth. What can be placed in the oral cavity to lessen a gag reflex? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 92

93 Normal Anatomic Landmarks
To correctly mount dental radiographs, the dental assistant must be able to recognize the normal anatomic landmarks on intraoral radiographs. Films are arranged on a mount for easy viewing. Films must be in order to avoid diagnostic errors. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 93

94 Maxillary Anterior Landmarks
Median palatine suture Incisive foramen Anterior nasal spine Nasal septum Nasal fossa Where are these landmarks located? What do they look like on a radiograph? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 94

95 Landmarks of the Mandible
Genial tubercles Lingual foramen Nutrient canals Mandibular canal Coronoid process Mylohyoid ridge External oblique ridge Mental ridge Where are these landmarks located? What do they look like on a radiograph? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 95

96 Tips for Mounting Radiographs
Handle films only by the edges. Label and date the film mount before mounting the films. Include the patient’s full name and date of exposure and the dentist’s name. Work with clean, dry hands. Use a definite order for mounting films. Use the “smile” line to mount bite-wing radiographs. What is labial mounting? What is lingual mounting? Which mounting is recommended by the ADA? What types of mounts are available? (Plastic, cardboard.) Double check mount for errors. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 96


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