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Chapter 41
Intraoral Radiography
Copyright 2003, Elsevier Science (USA).
All rights reserved. No part of this product may be reproduced or transmitted in any
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Produced in the United States of America
ISBN 0-7216-9770-4

Copyright 2003, Elsevier Science (USA). All rights reserved.
Introduction
 There are two basic techniques for obtaining
periapical radiographs:
• Paralleling technique.
• Bisection of the angle technique.
 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 Full Mouth Survey: FMX
 An intraoral full mouth examination is composed of
both periapical and bite-wing projections.
 This technique requires the use of intraoral film
that is placed inside of the mouth and is used to
examine the teeth and supporting structures.
 On 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.

Fig. 41-2 Mounted full mouth series with eight anterior films using the
paralleling technique.
Fig. 41-2 B

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.

Fig. 41-5 Positions of the film teeth and central ray of the x-ray beam in the
paralleling technique.
Fig. 41-5

Fig. 41-6 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.
Fig. 41-6

Fig. 41-7 This radiograph demonstrates a cone cut.
Fig. 41-7

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.

Anterior Exposure Sequence
 When exposing periapical films with the paralleling
technique, always start with the anterior teeth
(canines and incisors) because:
• The number 1 size 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.

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).

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.

Tips for Film Placement
 The white side of the film always faces the teeth.
 The anterior films are always placed vertically.
 The 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.

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 hands.
 Dispense the desired number of films and store them
outside of the room in which the x-ray machine is being
used.

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 remove any removable prosthetic
appliances from 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 hands and put on clean examination
gloves.

Maxillary Cuspid Region
 Insert the number 1 film packet vertically into the
anterior bite-block.
 Position the film packet with the cuspid and first
premolar centered. Position film as far posterior as
possible.
 With the film-holding instrument and film in place,
instruct the patient to close the mouth slowly but
firmly.
 Position the localizing ring and positioning
indicating device (PID), and then expose the film.

Fig. 41-10 Assembling the XCP (Extension-Cone Paralleling Instruments),
Anterior Assembly.
Fig. 41-10

Maxillary Central/Lateral Incisor Region
 Center the film packet between the central and
lateral incisors and position the film as far posterior
as possible.
 With the film-holding instrument and film in place,
instruct the patient to close the mouth slowly but
firmly.
 Position the localizing ring and PID and then
expose the film.

Fig. 41-11 Assembling the XCP (Extension-Cone Paralleling Instruments),
Posterior Assembly.
Fig. 41-11

Mandibular Cuspid Region
anterior bite-block. Center the film on the cuspid.
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 cuspid tip and to increase patient
comfort.

Fig. 41-14 Mandibular cuspid region.
Fig. 41-14

Mandibular Incisor Region
 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 the mouth slowly but firmly.
expose the film.

Fig 41-15 Mandibular incisor region.
Fig. 41-15

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 film in the midpalate area.
expose the film.

Fig. 41-16 Maxillary premolar region.
Fig. 41-16

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.
expose the radiograph.

Fig. 41-17 Maxillary molar region
Fig. 41-17

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.
 Slide the localizing ring down the indicator rod to the
patient's skin surface.
 Position the localizing ring and PID and then expose
the film.

Fig. 41-18 Mandibular premolar region.
Fig. 41-18

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.
expose the film.

Fig. 41-19 Mandibular molar region.
Fig. 41-19

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.

Fig. 41-20 The bisecting technique.
Fig. 41-20

Film Holders
 Although you may see operators asking the
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 Instruments
• EEZEE-Grip Film Holder (Snap-A-Ray)
• Stabe Bite-Block (Rinn Corporation)

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.
 The bisecting angle instruments (BAI) with aiming
rings dictates the proper PID angulation.

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.

Fig. 41-22 The arrows indicate movement in a horizontal direction.
Fig. 41-22

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.

Fig. 41-23 Correct horizontal angulation.
Fig. 41-23

Fig. 41-24 Incorrect horizontal angulation.
Fig. 41-24

Fig. 41-25 Overlapped contacts.
Fig. 41-25

Vertical Angulation
 Vertical angulation refers to the positioning of the
PID in a vertical, or up-and-down, plane.
 The vertical angulation differs according to 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.

Fig. 41-26 Vertical angulation of the PID.
Fig. 41-26

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 either longer or shorter:
• Elongated
• Foreshortened

Fig. 41-27 A, If the vertical angulation is to too steep, the image on the film
is shorter than the actual tooth. B, Foreshortened images.
Fig. 41-27 A & B

Fig. 41-28 A, If the vertical angulation is to too flat, the image on the film is
longer than the actual tooth. B, Elongated images.
Fig. 41-28 A & B

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.

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 90o
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 avoid cone cutting.

Fig. 41-29 C, D, Maxillary canine exposure.
Fig. 41-29 C & D

Fig. 41-30 C, D, Maxillary incisor exposure.
Fig. 41-30 C & D

Fig. 41-31 C, D, Mandibular canine exposure.
Fig. 41-31 C & D

Fig. 41-32 C, D, Mandibular incisor exposure.
Fig. 41-32 C & D

Fig. 41-33 A, D, Maxillary premolar exposure.
Fig. 41-33 A & D

Fig. 41-34 C, D, Maxillary molar exposure.
Fig. 41-34 A & D

Fig. 41-35 C, D, Mandibular premolar exposure.
Fig. 41-35 A & D

Fig. 41-36 C&D, Mandibular molar exposure.
Fig. 41-36 A & D

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.

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˚
vertical angulation.

Fig. 41-37 A +10˚ vertical angulation is used to compensate for the slight bend of the
upper portion of the film and the tilt of the maxillary teeth.
Fig. 41-37

Fig. 41-38 Bite-wing tab and film-holder.
Fig. 41-38

BWX 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
cuspids, both premolars, and often the first
molars on both the maxillary and mandibular
arches.
 The molar film should be centered over the
second molars.

Fig. 41-39 Premolar bite-wing. A, Film placement. B, Resultant radiograph.
Fig. 41-39

Fig. 41-42 The molar-bite-wing. A, Film placement. B, Resultant radiograph.
Fig. 41-42 A, B

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.

Basic Principles of the Occlusal Technique
 The film is positioned with the white side facing
the arch being 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.

Fig. 41-44 A, The central ray (CR) is directed at +65˚ to the plane of the film. B,
Relationship of film and position-indicator device. C, Maxillary occlusal radiographic
projection.
Fig. 41-44 A,B,C

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.

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 with
communicating concerning the physical needs of
the patient.

Fig. 41-45 Wheelchair bound patient receiving x-rays.
Fig. 41-45

Patients With Special Dental Needs
 Reasons for radiographs on 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.

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.
 For edentulous patients, either the 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.

Fig. 41-46 Mixed occlusal-periapical edentulous survey.
Fig. 41-46

Radiographs for the Pediatric Patient
 In children, radiographs are useful for detecting
conditions of the teeth and bones, for showing
changes related to caries and trauma, and for
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.

Fig. 41-47 The XCP instruments can also be used for the pediatric patient,
but the exposure time is reduced.
Fig. 41-47

The Patient Who Gags
 To help prevent the gag reflex, you must convey a
confident attitude.
 For the patient who has 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.

Normal Anatomic Landmarks
 To correctly mount dental radiographs, the
dental assistant must be able to recognize the
normal anatomic landmarks on intraoral
radiographs.

Maxillary Anterior Landmarks
 Median palatine suture
 Incisive foramen
 Anterior nasal spine
 Nasal septum
 Nasal fossa

Landmarks of the Mandible
 Genial tubercules
 Lingual foramen
 Nutrient canals
 Mental foramen
 Mandibular canal
 Coronoid process
 Mylohyoid ridge
 External oblique ridge
 Mental ridge

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.
 Use clean and dry hands.
 Use a definite order for mounting films.
 Use the “smile” line to mount bite-wing
radiographs (BWXs).

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.

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