Intra oral radiographic techniques

-what do we mean by intra-oral technique? We need to have small film if it is in the oral and that fits but this is not 100% true and not necessarily because sometimes we can use small films in extra oral, so extra oral and intraoral means that if the film is inside the mouth during radiograph then this is intra oral and if it is outside the mouth then it is extra oral therefore it does not depend on size. *Intraoral radiographs will show us the teeth and adjacent structures, *Extra oral radiograph it can show us teeth and surrounding structure but there are differences, what is the difference for example between periapical radiograph and panorama radiograph? -For example if I want to see caries which one is better? Periapical is better...why? Because periapical will achieve one advantage of ideal film placement which is the close relationship between the film and the tooth, it is very close so the image will be clear, essential resolution is high, around 20 lines per millimeter for the periapical but when the film outside the mouth "panorama" the film is far from the tooth, there is magnification, the film is not clear, spatial resolution is only 4 lines per millimeter. -So if we have a patient with caries we dont ask him to take panoramic radiograph to see caries; we ask for intraoral radiographs instead. -But for example impacted third molar is difficult to be seen in intraoral radiograph so I go for panoramic" extra oral radiograph. -So why intraoral radiograph? We will have the permission to see the deep surrounding structure which cannot be seen by visual inspection. If I can see the caries by my eyes I dont take radiograph, unless I want to see something else and suspect that caries reaches the pulp and there is a periapical lesion; in that case I will take periapical radiograph. But if it is simple case of pulpitis, reversible pulpitis I will go to the treatment
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without X-RAY. So it will improve the quality, the diagnosis and the treatment because if there is a diagnosis this is will be false negative or false positive and finally it will be so long treatment, extraction for example.

*Types of Intraoral RADIOGRAPHS:

1-PERIAPICAL RADIOGRAPH: -In this type of intraoral radiographs, we expect to see at least 2mm beyond the apex.

-so periapical will show me:1-crown 2-bitewing:

2-root 3-peri-apex area

-From it is name it means the maxilla and the mandible, it shows me the crowns for upper and lower and part of the roots (1/3-2/3 of the roots and adjacent bone). -So if the student showed me crowns of lower teeth without the roots it means incorrect film placement and he will lose marks, in this type of radiograph we expect to see both of the upper and lower teeth equally. So the occlusal plane must divide the film into two halves.

*How to place the film: The film has two sides; one is completely white and the other one is coloured. The white side should be facing outside (The ring/PID), why? Because we have the lead foil in the coloured side, and I do not want the lead to absorb some of the x-rays, I want it to be just at the end, when the beam reaches the film, whatever is left there from the beam, it will be absorbed by the lead.

-This is actually the bite-block, it has a slot so it can fit the film tightly and hold it well. -In addition, as we remember, there is a dot in the film which enables us to know the right from left, this dot we should put it in the slot; dot-inthe-slot, why? Because if you put it somewhere else, it will be casting an image of the bone, and this dot actually has a density, it will be dark, so it will mask an area of the patient that might have some changes or disease. While if you put it in the slot, it will be on an area that is covered by air

-The doctor pointed at a dot appears in a radiograph in the slides, he said it is not important if the dot appears on the mandible or the maxilla in case of bitewing radiograph. -But if appears in periapical radiograph, the dot must be on occlusal plane and must not be at area on the apex. So we have to remember when we put the film in the holder to put the dot in the slot.

3-occlusal radiograph: -The size of occlusal radiograph films four times bigger than other films, we use it to see large number of teeth and large segment of dental arch. -We have six types for occlusal radiographs "maxilla: 3 types, mandible: 3 types" later on we will talk about it.

-When I take a radiograph I should ask myself: Will I get benefit from it? Is the benefit more than the risk? If yes we go for the radiograph. -The frequency of taking radiographs depends on whether the patient is high caries risk or nor, and if there is indication for high frequency of caries then you must see him/her at short periods(every 3 months).

*Now the dr started to talk about the something called 20 CMS (complete mouth series): It is name is twenty CMS, why? Because it is 20 films for each patient, actually in some schools they ask the student to make 20 CMS, it shows me the condition of all teeth and the surrounding bone, and to see areas of different angulations to get the general condition of the jaw, bone.

-However CMS or CMRS (complete mouth radiographic series) it is not used in some universities, in our university here we dont prefer to do CMS and we usually take one or two radiographs, if we need full coverage we go for panoramic radiograph instead of taking 20 films for the patient(NOT ALL patients need CMRS) . *CMS: complete mouth Series, it is twenty films: -5 of them periapical films of upper anterior -3 periapical films for lower anterior -4 periapical films for maxillary posterior teeth -4 periapical for mandibular posterior teeth - 4 bitewing films *so they become 16 periapical films and 4 bitewing films. - Film size depends on your technique, ideally we use size one for anterior teeth and we use size two for posterior teeth and we can change the size according to the patient jaw size.

*Summary for CMS: - It is a series of IO radiographs that shows the entire tooth bearing area In U/L jaws (dentulous and edentulous). - 20 films. - BW only in areas with inter-proximal contact. - Film size indicated by technique and size of arch.

*Periapical radiograph: main indications:

1- Detection of caries and periapical infection.Actually it is more for periapical infection because caries is better to be seen by bitewing.

2- Assessment of periodontal status: Like widening of PDL space and loss of bone, calculus. 3- After trauma of tooth and supporting structures (bone). 4- Assessment of presence of impacted or un-erupted tooth: like in third molars but sometimes we need panoramic radiograph especially for patients with limited mouth opening and gagging reflex which usually initiated when the film touches the dorsum of the tongue or the soft palate. 5- Assessment of morphology before extraction: in the surgery we will learn that we need x-ray before extraction, for example to know there are no ankylosis and no dilacerations before the extraction 6- During endodontic treatment: to see the working length. *nowadays we use cone beam radiograph in endo but not during the treatment "not to check the working length "but when we have problems, like fracture, to detect a cystic lesion which cannot be seen in intraoral radiograph we need the third dimension we will think about cone beam CT. 7- Assessment of position and associated implants: for example osteointegration can be seen in periapical radiograph.
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*Ideal positioning requirement: -If we want to make radiograph we have to remember five points: 1- Correct patient position. 2- Correct film position. 3- Correct vertical angulation. 4- Correct horizontal angulation. 5- Centering the beam. *We will start talking about each point: 1-patient position: -The mid sagittal plane must be Perpendicular to the floor and the occlusal plane must be parallel to the floor. - If the patient opens his mouth during x-ray, the mandible will go down so you have to tilt the plane (head) slightly backward to make sure that the mandible, the jaw being imaged, is parallel to the floor. And you have to raise the chair or lower it according to the jaw *Film -tooth relationship.. In ideal positioning we need: 1- Minimal tooth film distance (to be in contact) 2- We need parallel tooth- film placement. But we cannot achieve this because the teeth are tilted, and when the film is in contact to the tooth the film will not be parallel. 3- X-ray perpendicular to both. 4- In parallel technique the source of radiation should be as far as possible from the tooth.

-Then I want to make parallel technique and I want the film to be on contact to the tooth at the same time and if it is then it won't be parallel, so what to do? -We move the film to the mid of palate or the mid surface of the tongue, to have parallelism. But when we put the film far we will make problem, the problem of magnification, like panorama has problem of magnification because it is far from the tooth

*In the parallel technique, we should use holding instrument (pic #1)to ensure that the film is parallel to the tooth/object. - Film, tooth, ring (in front of the PID) all are parallel, and x-ray is perpendicular to them. -This is correctly placed, because you placing your film parallel to the tooth.

#1
Sometimes, you can insert your film inside the patient mouth, but actually, you are NOT parallel, the film is not parallel to the tooth, so this radiograph will be distorted! Therefore, you have to push this film more inside the patients mouth, in order to be more parallel to the tooth. Note: the ring and the film/bite-block are already parallel because they are fixed assembling together from the manufacturer. Now, when you place your film in the bite-block (where the white film in pic #1 is placed) inside the patients mouth and make it parallel to the tooth, then the ring is FOR SURE is parallel to the tooth. *Radiograph #2..it is made parallel, but it is too close to the ridge, and the film cannot be pushed in the bone/ridge, so you will miss the root (apically), and you will end up with space in the film. In addition, ideally, the patient should bite #2 that block, there should not be a space between the tooth and the bite-block (in this picture there is a space between the incisal edge and the bite-block). Because if we have a space this means that the film is covering an area where you have no tooth and it is missing an area where you have a tooth/root. Note: pushing the film inside the patients mouth (away from the teeth), will increase the magnification and as a result, it will decrease the sharpness (penumbra), to compensate for this, the target-film distance
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should be increased, by using a longer PID, and also we should increase the exposure time according to inverse square law. *Again when you put the film in the mid of the palate you will get magnification, so how we overcome the magnification? -Simply by using long cone technique. So if we took a radiograph by parallel technique using short cone our radiograph will be wrong, it must be long cone"61 inch","40 cm". Paralleling technique (long cone technique, or right angle technique) and this can be achieved by putting the film far toward the mid of the palate, short cone will end up with magnification, long cone will end up with minimum magnification. 2-film position: -Film holder: We will not use the patient finger in parallel technique to stabilize the film; we use holders, but what kind of holders? -The most important one is "Rinn XCP "and it is the one which we use in the clinic, if it is: 1) Yellow holder we use it for posterior teeth 2) Blue holder for anterior teeth 3) Red holder for bitewing 4) Green one we use it for endodontic. -After we use holders we have to sterilize them, because they are semi-critical devices, never ever use the same film holders for two patients.

*Film holder devices: 1- Precision attachment: the precision instrument includes metal collimating shields and film-holding devices that restrict the size of the xray beam to the size of the film.

2- Stable (Styrofoam bite blocks): disposable film holder made from plastic and we get rid of it after each use.

3- Snap A-RAY-film holder: we use it with -patients with gagging reflex -patients with shallow palates because the patient will hold this holder with his hand and it not bulk so he can move it as far as possible -we use it also in third molars *but if we dont have this one we use our hands and we can use hemostat instead of it, it will help us to catch distal located third molars. -Hemostat: a small surgical clamp inserted through a rubber bite block also can be used to stabilize a film

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*Film size and placement: 1) Anterior region: - Long axis of film packet should be vertical. - Size 1 films "ideally". In our clinics the technicians prefer to use size 2 in order to cover many teeth, because usually the patient comes and need a radiograph for his central, lateral incisors and canine so we use film size 2 to save films as much as we can. And that means we have to adapt our techniques according to the clinic. 2) Posterior region: - Size 2 films. - Long axis of film packet should be horizontal. *Note: The area of interest must be in the middle of the film, if we want to take an image for canine we make sure that the canine is in the middle of our film for example. *Note: 1/8 inch must be beyond the incisal edges from occlusal plate and at least 2 mm periapically.

3-correct vertical angulation: -What do we mean by vertical angulation? It is the angle between the xray beam and the axial plane "occlusal plane, horizontal plane" *We have positive vertical angulation and negative vertical angulation. - If I want to make an image for maxillary teeth the vertical angulation will be positive because it will be above occlusal plane "horizontal plane, axial plane. and in case of mandible it will be negative. -At the horizontal plane the angulation will be zero above it positive and below it negative.
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*Note: In parallel technique by using holders no need to memorize vertical angulations because you will just follow your holder angulation. -The vertical angulation: the central beam should be perpendicular to the long axis of the tooth, and this is done automatically by using holders. -Usually the true vertical angulation of the root varies from vertical axis of the crown by 5-20 degrees 4- Horizontal angulation: -It is the angle between the x-ray beam and the mid sagittal plane. - If I want to image central incisor the cone must be toward the central incisor, the beam should be passing between central incisors, I will not ask you to make a radiograph for central and put your cone here "at the canine for example" because it means incorrect horizontal angulation and will result in overlapping. -If I want to make image for premolars the central beam if we imagine it as coming out from the cone must pass through contacts and by this we will have correct horizontal angulation . -incorrect horizontal angulation it will lead to overlapping. -The correct horizontal angulation should be through the contact areas of the teeth (i.e. perpendicular to the outer surface of the tooth) and again if it is incorrect it is will lead to overlapping. *The overlap is due to having the beam not going just in the contact point and the resultant radiograph will be something like radiograph below -Actually, in this radiograph, I cannot assess the bone between the two teeth and the proximal caries if they exist.

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*Note: the more posterior the radiograph the more the horizontal angulation. -We have problem in the maxillary canine: usually when the students make an image for the canine there will be overlapping between canine and first premolar? How to solve this problem? -By making the cone a little bit distally and change the horizontal angulation in order to over the contact and this is called distal shift, so if we bring the beam through the canine it will be overlapping. 5- Centering the beam: -the central ray must be directed to the tooth and the film through a point that allows complete coverage of both ,otherwise it will be cone cut(partial image) and it is the most common mistake made by the students. *Cone cut: area will not be covered by beam; result when your cone is not following the ring of the holder.

-Sometimes the student will put the cone on the central of the ring but because of movements made by the patient it will change and result in cone cut.

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*General guide lines:

1. White surface of the film always faces the beam 2. Anterior films are always vertical, posterior films are horizontal. 3. The dot in the slot. 4. Place the film away from the teeth (in the mid of the palate) 5. Use film holders and centering the beam. 6. Ask the patient to close slightly to stabilize the film. 7. The patient must close his lips on the holder. -The film will be opposite to air, and part of her root will not have a film on the opposite side. Therefore, this is the resultant radiograph; the apices will be cut, and we will have an empty area below the crowns, which was covered by nothing.
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* Exposure sequence: -We usually follow the sequence in CMS to avoid repeating and minimize movement; we usually start with anterior teeth, why? Because: * Film smaller easier to tolerate by the patient. * Less likely to cause gagging. -Then we continue to the posterior teeth: We start with premolar then molars same as reasons as above..the movement will be like a clock. -For anterior teeth begin with upper right canine all the way to the upper left canine then lower left canine then all the way to the lower right canine then to the lower left canine. *But for posterior teeth begin with 1. Maxillary right quadrant exposes premolar film then expose molar film 2. Mandibular left quadrant expose premolar film then expose molar film 3. Maxillary left quadrant expose premolar film then expose molar film 4. Mandibular right quadrant exposes premolar film then expose molar film *We usually do bitewings before periapical parallel technique.

**Advantages of parallel technique:

(Simple, accurate, the shadow will be over the tooth, duplication) -American academy of oral radiology advises using parallel technique not bisecting technique because it is geometrically better. (Dimensional accuracy and high details) -Reproducible which means we can use the technique again and again for the same patient with the same accuracy. -Shadow of zygmotics bone will be above root. -it is Simple -Duplication: the paralleling technique is easy to standardize and can be accurately duplicated or repeated when a serial radiographs are indicated.

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**Disadvantages of parallel technique:

(Film placement & discomfort) -Film position can be uncomfortable "arch anatomy sometimes makes it impossible" -Holders in lower third molars are very difficult. -However of its disadvantages this is what we do in our school.

**Difficulties in positioning may be because of: Shallow palate Tori Third molar Gagging Endodontic Children Handicapped patient.

*Shallow palate:
-If we have shallow palate, we can increase dimensions by putting cotton rolls above and below the holder, also we can increase the vertical angulation by 15-20 degrees. -In case of lower premolars the shallow floor of the mouth the patient also will feel pain what we have to do is to put the holder like this "under the tongue "and then push the tongue with the holder, we can gently bend the corner of the film but sometimes this will result in artifacts.

*Tori:
-If the patient has Tori it is better to put the film on the far side of the torus, if it is in the mandible we put it between the torus and the tongue.

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*Mandibular third molars:

-Film cannot reach the distal surface of third molar, and the solution for this we direct the beam from distal surface. -Another technique we can use hemostat; draw a vertical line dropped from the outer corner of the eye and put another point 1cm above the lower mandibular border and this will be your point of entry, the central ray directed to this and this another solution for impacted third molars. -If both techniques failed then go to panorama. *Gagging: Gagging is common in clinic: We ask the patient to concentrate on breathing from the nose during procedure or we ask him to count number, anything to destruct his thinking. We use bisecting angle technique in order not to touch the palate. In severe cases may spray palate with local anesthetic before film positioning. Another solution for gagging dont put the film at the surface of the tongue, we put the film horizontally and made it with bisecting angle technique. This solution can also be applied for kids.

*Endodontic:
-Difficulties of placing films are because of rubber dam and clamps. *Solutions: using a special film holder (its color is green) which has a small basket in the bite platform to accommodate for the handles of endo instruments. -Another solution if these holders are not available we can use hemostat or snap-A-ray. -The third solution: take bisecting angle radiograph but I cannot depend on this radiograph to take the measurements because of magnification
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problems, and in endo I need to know the real length of the tooth. So we need to put the file inside the tooth to know the real dimension and I know exactly the length of the file that I inserted (for example I measured it by a ruler 10mm), when I took a radiograph, on the film the file appear as 15 mm. So I know that the tooth is 1.5 magnified. And I know that the dimension of the tooth on the radiograph by that relation

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