Ce 462

Digital Imaging Techniques and Error Correction
Gail F. Williamson, RDH, MS

Continuing Education Units: 4 hours
Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce462/ce462.aspx

Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.
Clinical errors occur as a consequence of improper patient preparation or management, technique and
exposure. Correct technique and proper patient management skills are essential to maximize the outcome
and the information obtained from digital radiographic images, while at the same time minimizing patient
radiation exposure. This course will provide an overview of digital imaging, a review of technique principles
and the identification and correction of common errors that occur in digital intraoral and panoramic imaging.
Conflict of Interest Disclosure Statement
The author reports no conflicts of interest associated with this work.
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Overview
Clinical errors occur as a consequence of improper patient preparation or management, technique and
exposure. Correct technique and proper patient management skills are essential to maximize the outcome
and the information obtained from digital radiographic images, while at the same time minimizing patient
radiation exposure. This course will provide an overview of digital imaging, a review of technique principles
and the identification and correction of common errors that occur in digital intraoral and panoramic imaging.
Learning Objectives
Upon completion of this course, the dental professional should be able to:
Describe the principle imaging concepts used in digital intraoral and panoramic imaging.
Discuss the receptors used in digital radiography.
Identify and correct common errors that occur in digital intraoral radiography.
Identify and correct common errors that occur in digital panoramic radiography.
Course Contents
Glossary
Introduction
Digital Intraoral Imaging Overview
Receptor Types
Advantages and Disadvantages
Review of the Basic Principles of Intraoral
Radiography
Rules of Accurate Image Formation
Review of Techniques
Common Intraoral Errors
Technical Errors
Exposure Errors
Miscellaneous Errors
Digital Panoramic Imaging
Basic Principles of Panoramic Imaging
Focal Trough
Patient Preparation and Positioning
Criteria for a Diagnostic Panoramic Image
Common Panoramic Errors
Alignment Errors
Imaging Errors
Summary
Course Test Preview
References
About the Author
on the energy of the x-ray beam and composition of

the absorber
analog data - analog data is characterized by a
continuous grayscale from black to white
analog to digital converter (ADC) - device that
converts the analog output signal into numeric data
based on the binary number system of 0 and1
area array - matrix or arrangement of pixels in
columns and rows used in intraoral direct digital
imaging
artifact - an object on a radiograph that is not part
of the actual image which may render the image
non-diagnostic
attenuation - process in which an x-ray beam is
reduced in intensity by passing through material. A
combination of absorption and scattering processes
results in a reduction of the beam intensity
binary number system - computer language in
which two digits, 0 and 1, are used to represent
information
Glossary
absorption - transfer of some or all of x-ray

photon energy to material or matter; dependent
brightness - digital equivalent to density, or overall

degree of image darkening.
2
cassette - a metal, plastic or cardboard light-tight

container that holds a plate receptor for extraoral
imaging
double exposure - a radiographic image that has

superimposed images due to exposing a receptor
twice prior to scanning; this error is only possible
with plate receptors
charge coupled device (CCD) - solid-state,

silicon chip detector that converts light or x-ray
photons to an electrical charge or signal
electron well - individual pixel into which x-ray or

light energy is deposited during x-ray exposure
collimation - device used to restrict the size and

shape of the x-ray beam
elongation - image distortion in the vertical plane

that produces a long or stretched out version of the
recorded structures rather than their true shape and
dimension; usually the apex is not visible
complimentary metal oxide sensor (CMOS)solid-state detector similar to the CCD with builtin control functions, smaller pixel size and lower
power requirements
emulsion - plate receptors have a crystalline

halide emulsion of a europium-activated barium
fluorohalide that stores the latent image
complimentary metal oxide sensor active pixel

sensor (CMOS-APS) - CMOS detector with active
amplifying transistors integrated in each pixel to
decrease noise and improve signal output
exposure time - regulates the period of time over

which electrons are released from the cathode;
altering the time setting influences the quantity of
x-rays and image density or darkness
compression - computer methods used to

reduce the image file size so it can be transmitted
faster and take up less storage space;
compression schemes can be lossy or lossless
focal spot - anode tungsten target where x-rays

are generated; focal spot size should be as small as
possible in the range of .5 to 1.5 mm; the size has
an influence on image quality in terms of sharpness
and geometric distortion
contrast - the difference in densities between

various areas on a radiograph; high contrast
images have few shades of gray between black
and white while low contrast will demonstrate
more grays
focal trough - area or zone of sharpness in

panoramic imaging where the jaws must be
positioned in order for the structures to be in focus
on the resulting image
density - overall degree of blackness or image

darkening of an exposed film; comparable to
brightness in digital imaging
foreshortening - image distortion in the vertical

plane that produces a short, stumpy version of the
recorded structures rather than the true shape and
dimension of the structures
diagnostic - radiographic image that properly

records and adequately covers all structures
present in a given anatomical area with optimal
density and contrast
Frankfort plane - used to align the vertical plane of

the head in panoramic imaging; line or positioning
light that connects the tragus of the ear to the
infraorbital rim and is aligned parallel to the floor
digital image a video image in pixel format

that can be stored in the computer memory for
processing
ghost image - an artifact produced in panoramic

radiography by a remnant image from the opposite
side of the dental arches during exposure; some
ghost images are inherent in panoramic technology
while others can be avoided through proper patient
preparation
digitization - conversion of an incoming analog

signal into a digital or numeric value for storage
and processing
direct sensor - receives radiation directly like film
and deposits the energy in the electron wells or
picture elements
gray level - measure of image brightness or

intensity in a range between black and white
3
horizontal angulation - movement of the x-ray

head and PID in a horizontal plane; right to left, or
mesial to distal, which controls the ability to direct
the x-rays through the proximal surfaces of the
teeth.
marginal - radiograph that may be adequate and

diagnostic only in par; it may be adequate when
combined with other views taken in survey that
demonstrate the compromised area
midsaggital plane - vertical plane that divides the
body in half and is drawn at the midline; used in
panoramic imaging to center and position the head
in the horizontal plane
image enhancement - image processing

operations that are used to view details of the
image in different ways; sometimes referred to as
manipulation
milliamperage (mA) - regulates the low voltage

electrical supply by adjusting the number of
electrons flowing in the electrical circuit; altering
the milliamperage influences the quantity of x-rays
produced and image density or darkness
image matrix - layout or grid of pixels in rows

and columns with each pixel corresponding to a
specific location and representing the brightness
or intensity in that location
indirect sensor - receptor receives x-rays upon
exposure and stores the energy until released via
a laser scanning process
non-diagnostic - radiographic images in

which any error in patient preparation, receptor
placement, angulation, exposure or processing
prevents visualization of the required region of
interest; this type of radiographic image would
require a retake
interproximal - the areas between teeth in the

same arch, mesial and distal; the x-ray beam
must be directed through the proximal surfaces
in order to open teeth contacts and examine for
caries
overexposure - a radiographic image that is too

dark or high in density due to incorrect and/or
excessive exposure factor settings
kilovoltage (kVp) - regulates the high voltage

electrical circuit by adjusting the potential
difference between the electrodes; altering
the kilovoltage setting influences the quality or
penetration of the x-rays and image contrast
photostimulable phosphor plate (PSP) - digital

receptor with a polyester base coated with a
crystalline halide emulsion
photostimulation - emission of visible light after
excitation by a laser light beam
latent image - the energy stored in a receptor

that represents the captured data prior to
processing and viewing the visible image
photomultiplier tube - electron tube that converts

visible light into an electrical signal
linear array - solid-state detector that consists

of a few rows of pixels; used in direct digital
extraoral imaging
pixel - picture element; individual cell of the image

matrix in which the value of the cell determines
brightness
lossy - storage method in which some data is

lost but the compressed file is still capable of
producing a diagnostically acceptable image
positioning indicating device (PID) - device

located at the end of the tubehead used to align
the x-ray beam in the vertical and horizontal planes
and to center over the receptor; formerly known
as the x-ray cone radiolucent - dark or black areas
on the radiograph where x-rays penetrated the
structures and interacted with the receptor
lossless - storage method in which no

information is lost in the compression of a file
magnification - equal enlargement or distortion
of the radiographic image; deviation from its
actual true overall size; magnification can be
minimized by controlling receptor and source
distance factors
radiopaque - light or white areas on the

radiograph where x-rays were partially or
completely absorbed by the structures
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Random Access Memory (RAM) - temporary

memory of the computer in which programs and
information are stored
vertical plane - movement of the x-ray head and

PID in a vertical plane (up and down); used to
control the length of recorded object(s)
receptor - any device or medium that transforms

x-ray energy into a latent image that can be made
visible by processing procedure
XCP (eXtension Cone Paralleling) - a receptor

holding device designed to maintain a parallel
relationship among the receptor, teeth and the PID
resolution - measures how well a radiographic

image reveals small objects that are close
together; measured in line pairs per millimeter
Introduction
Digital radiographic imaging in dentistry is nothing

new. This technology was first introduced in the
mid-1980s but has made significant entry into the
private practice, military dental services and dental
educational institutions in the last decade. As
with any new technology there is a learning curve
and a transition time before it becomes widely
adopted, but its only a matter of time before
digital imaging replaces traditional film. There
are many conveniences associated with digital
imaging that make it an attractive alternative to
film, but the basic mechanics and principles of
radiographic technique remain the same. Like
film-based imaging, the clinician is responsible
for the majority of errors and retakes that occur in
dental imaging. Regardless of the receptor, a nondiagnostic radiographic image does not provide
the information necessary to render a diagnosis
or to provide proper treatment and results in
increased radiation to the patient. Clinician errors
occur as a consequence of improper patient
preparation or management, technique and
exposure. Correct technique and proper patient
management skills are essential to maximize
the outcome and the information obtained from
digital radiographic images, while at the same
time minimizing patient radiation exposure.
This course will provide an overview of digital
imaging, a review of technique principles and the
identification and correction of common errors that
occur in digital intraoral and panoramic imaging.
sensor - a receptor device used in digital

radiography
shape distortion - deviation from the true
shape and size of an object related to unequal
magnification of different parts of the same object;
minimized by object receptor parallelism and right
angle entry of the x-ray beam
sharpness - ability of a radiograph to define an
edge or display density boundaries
split beam radiography - use of a narrow vertical
slit x-ray source rotating at the same speed as the
image receptor but in opposite directions around a
stationary object; structures are depicted sharply
because they move past the slit at the same rate
as the receptor
storage phosphor - another term or name for
photostimulable phosphor plate receptors
teleradiography - process of remote transmission
and viewing of digital images
tomography - technique that provides an image
of any selected plane through the body while the
images of the structures above and below that
plane are blurred out of focus
Digital Intraoral Imaging Overview
underexposure - a radiographic image that is too

light due to incorrect and/or insufficient exposure
settings
Prior to the acquisition of intraoral digital images,

the clinician must create or access the patients
record and create or select a template for the
intended survey. As in film-based radiography,
digital imaging requires x-ray interaction with
a receptor, latent image processer and image
viewer. The receptors (direct or indirect sensors)
used in digital imaging are faster, and more
sensitive thus requiring less radiation than film.
unsharpness - loss of image edge detail due to

production of a fuzzy zone (penumbra) or false
shadow around the actual image; unsharpness
can be minimized by controlling receptor and
source distance factors
The energy received by the receptor must be

converted to digital data before it becomes usable.
This process differs slightly depending on the
type of digital system and receptor that is used.
Essentially, the information is transformed into
numeric or digital data which translates ultimately
into 256 shades of gray (0 black to 255 white).
x-rays interact with the phosphor, a latent

image is formed and stored until the energy is
released during a laser scanning process. The
laser beam releases the energy in the form of
light proportional to the energy absorbed by
the plate. The light is captured, intensified by
the photomultiplier tube and converted into an
electronic signal. The ADC digitizes the data and
displays the image on the computer monitor. As
such, the scanning step delays image display
on the monitor slightly. Before the plates can be
reused, the remnant energy must be removed
or erased by exposure to intense light. In some
updated or newer systems, erasure is completed
after scanning but before the plate exits the
scanner. PSP receptors have a larger surface
area, are thin and wireless and can be used like
film. The plates require careful infection control to
avoid cross-contamination and gentle handling to
avoid plate scars and image artifacts.
Receptor Types
Digital receptors come in two basic formats; rigid
wired, or wireless, sensors or phosphor plates.
Rigid digital receptors are based on chargecoupled device (CCD) or complimentary metal
oxide semiconductor (CMOS) technology and
are categorized as direct sensors. CCD, CMOS
and CMOS-APS sensors are solid-state detectors
made of silicon arranged in an area array of x-ray,
or light sensitive pixels or electron wells. When
x-rays strike the silicon, an electrical charge
is emitted and deposited in the electron wells.
The electrical charge is converted into a gray
scale image via the analog-to-digital converter
(ADC). Wired sensors communicate with the
computer via an electrical cable, while wireless
sensors powered by a battery communicate via
a radio signal. Direct sensors are available in
sizes comparable to 0, 1, and 2 film packets
but are thicker and rigid in construction. Not all
manufacturers have multiple sizes. The active
surface area is smaller than film, so the amount of
coverage is somewhat reduced. Direct detectors
can be reused for each successive projection and
the acquired image can be viewed almost instantly
after exposure. Rigid sensors require careful
infection control and barrier coverage to avoid
cross-contamination.
Advantages and Disadvantages

Less radiation exposure The National Council
on Radiation Protection and Measurements
(NCRP) assessed the technological
advancements and the ALARA concept in
2003. When all NCRP recommnedations are
met (including film speed, total digital imaging,
rectangular collimation, selection criteria, etc.)
the amount of radiation is significantly reduced.
The choice to use protective aprons on adult
patients is up to individual dental offices only
if every NCRP recommendation is employed
or unless required by the state. Thyroid
shielding with a protective thyroid shield or
collar is strongly recommended for children and
pregnant women, as these patients may be
especially susceptible to radiation effects.
Time Savings - less time is spent away from
the patient during processing and mounting
activities which provides more time for patient
education and treatment.
Image display - images can be displayed for
patient viewing and enlarged for the purposes
of patient education and treatment plan
presentation.
Storage and transferability - radiographs are
stored as digital images in the computer; they
can be transferred during the referral process
to specialty dental practices and sent with
HIPAA permission to insurance companies
for more efficient claims processing. Digital
Photostimulable phosphor plates (PSP), also

known as storage phosphor plates (SPP), are
another system for capturing intraoral digital
images. PSP are categorized as indirect digital
sensors as they require a scanning process to
digitize the image. PSP are flexible, wireless
receptors similar in size and thickness to film.
Phosphor plates are available in the same sizes
as intraoral film including 0, 1, 2, 3 and 4. Not
all manufacturers produce plates in multiple
sizes. An individual plate must be used for
each projection in a survey, just like film. The
phosphor plates consist of a plastic base coated
with a crystalline halide emulsion of a europiumactivated barium fluorohalide compound. When
6
radiographic images can be incorporated into

a complete electronic patient record with less
likelihood of lost records or images.
Protection of the environment - advantages
with reduced waste production and disposal
from film wrappings and processing chemicals.
A complete electronic patient record helps to
reduce paper consumption and associated
costs.
The disadvantages to digital imaging include the
initial cost of the system hardware, software, and
adaptation or replacement of exisitng equipment.
There is a learning curve for the dental
professional in using digital radiography system,
getting used to the placement of the sensor and
software operation. Finally, to avoid any possible
legal issues, the original image(s) should be saved
before performing enhancements or manipulation
for further diagnostic evaluation.
Figure 1. Rigid receptor should be covered with

internal and external barrier to protect the receptor
from cross-contamination with oral fluids.
critical importance. Plates must be inserted and

sealed inside a barrier before placement in the
mouth. After the plates are exposed, the external
barrier should be cleaned using disinfectant
hand soap, rinsed and dried. Following glove
removal and hand washing, the plates can be
dropped out of the barrier into the transfer carrier
with the exposure side down. Since there are
a number of plate systems on the market, it is
best practice to consult and follow the specific
manufacturers recommendations for plate
handling and disinfection. The importance of
effective infection control was demonstrated in
an investigation by Kalathingal and others. The
study found that that nearly 58% of the phosphor
plates tested yielded bacterial colonies and
nearly 16% of those demonstrated hemolytic
growth. The investigators recommended periodic
ethylene oxide gas sterilization of phosphor plates
with re-emphasis of proper handling for barrier
placement and removal.
The primary disadvantages with direct digital

receptors are the rigidity and thickness of the
receptor and presence of the wire. The lack of
flexibility and the attached wire may interfere
with optimal receptor placement and produce
discomfort both of which may result in more
retakes. Infection control is another challenging
aspect of digital imaging because rigid digital
receptors cannot be sterilized. However, they
can be disinfected with ADA or EPA approved
products and typical disinfection techniques.
The clinician must follow the manufacturers
instructions for proper preparation and coverage
of the receptor, as well as barrier removal
techniques. Direct saliva contact with the receptor
and electrical cable must be avoided to prevent
cross-contamination. Several investigations have
indicated that the barriers used on rigid digital
sensors can become torn during use, resulting in
contamination of the sensor with bodily fluids. To
protect rigid sensors more effectively, the Center
for Disease Control (CDC) recommends a double
barrier approach with both an internal and external
barrier. (Figure 1)
Review of the Basic Principles of

Intraoral Radiography
Rules of Accurate Image Formation
In order to produce diagnostic intraoral images,
the Rules of Accurate Image Formation must be
applied. The rules listed below include those that
can be controlled by the clinician.
1. The x-ray source-to-object distance should be
as long as practical.
2. The object-to-receptor distance should be as
short as possible.
3. The receptor should be parallel to the long
axis of the tooth.
Phosphor plate receptors are wireless and

more flexible than rigid receptors, producing less
discomfort for the patient. Disadvantages of
phosphor plate systems include plate artifacts,
plate longevity, image resolution and the scanning
step. Effective infection control procedures are of
7
4. The x-ray beam should be directed at a right

angle to both the tooth and receptor.
placed into the mouth parallel to the crowns of

the maxillary and mandibular posterior teeth. The
horizontal angulation directs the x-rays through the
contacts of the posterior teeth. The clinician may
find it helpful to place a fingertip in the contact point
to visualize the correct horizontal entry of the x-ray
beam and avoid overlapping. In addition, most PID
collimators have lines on them that can be used
to sight the entry of the x-ray beam through the
contact points. Receptors may be positioned in the
horizontal or vertical dimension and may be taken
in both the posterior and anterior segments of the
dentition.
When these rules are followed, the image quality

will be optimal but if violated, image quality
can be compromised. A review of the basic
techniques used in intraoral digital imaging
follows.
Review of Techniques
The paralleling technique is the preferred
method for periapical imaging because it most
closely conforms to the Rules of Accurate
Image Formation. The paralleling technique
is accomplished by placing the receptor
parallel to the long axis of the tooth. Once
this parallel relationship has been established,
the central ray of the x-ray beam is directed
perpendicular to both the tooth and receptor.
Receptor instruments with x-ray beam guides
help standardize technique and avoid errors,
particularly cone cuts. The paralleling technique,
when performed correctly, is superior to the
bisecting angle technique.
The bisecting angle technique is considered to

be a secondary or alternative periapical imaging
technique. At times it may not be possible to
achieve a parallel placement of the receptor
due to anatomical factors, patient discomfort or
cooperation issues. This technique is accomplished
by placing the receptor as close to the tooth as
possible in an angular position. The central ray
of the x-ray beam is directed perpendicular to an
imaginary line that divides or bisects the angle
formed by the long axis of the tooth and the plane
of the receptor. When the x-ray beam is not
directed perpendicular to the bisecting plane, errors
in the vertical plane will occur.
The bitewing technique is a paralleling

technique used to examine the crowns and
interproximal surfaces of the teeth. When taken
correctly, bitewings are particularly useful in
the detection of dental caries and evaluation
of alveolar bone levels. The receptor must be
Common Intraoral Errors

Technical Errors
Elongation is a form of shape distortion in which
the projected image is longer than the actual
Figure 2. In the paralleling technique, the

receptor is placed parallel to the long axis of the
tooth and the central ray is directed at a right
angle to both.
Figure 3. In the bitewing technique, the x-rays

are directed through the proximal contacts of the
posterior teeth and at +5 to +10 vertical angle.
Figure 5. Elongation is an error in vertical angulation

that produces a longer than normal image of the
teeth and surrounding structures.
Figure 4. In the bisecting angle technique, the

receptor is placed angular to the teeth with the
central ray directed at a right angle to bisecting
plane.
objects. This is caused by incorrect x-ray beam

angulation in the vertical plane. If the PID is
under angulated or too shallow relative to the
long axis of the teeth, an elongated image will
be produced. With the paralleling technique,
elongation occurs when the PID is less vertical
than the long axes of the teeth. In bisecting
angle, elongation occurs when the PID is less
vertical than the bisecting plane that divides
the angle formed by the teeth and the receptor.
With rigid sensors, elongation can occur with
paralleling instruments if the biteblock does not
position the sensor parallel to the teeth and
external ring beam guide. If adhesive type
disposable biteblocks are used, the receptor can
pop off the biteblock, producing image elongation.
With plate receptors, curvature of the plate
during placement and exposure can produce an
elongated appearance as well. Length accuracy
is critical in many dental procedures and a retake
is usually indicated when elongation is present.
In either instance, elongation is corrected by
increasing the vertical angulation.
Figure 6. Foreshortening is an error in vertical

angulation that produces a shorter than the normal
image of the teeth and surrounding structures.
paralleling technique, foreshortening occurs when

the PID is more vertical than the long axes of
the teeth or when the receptor is placed angular
rather than parallel to the teeth. In bisecting
angle, foreshortening occurs when the PID is
more vertical than the bisecting plane that divides
the angle formed by the teeth and the receptor.
Length accuracy is critical in many dental
procedures and a retake is often indicated when
foreshortening is present. In either instance,
foreshortening is corrected by decreasing the
vertical angulation.
Foreshortening is another form of shape

distortion in which the projected image is shorter
than the actual objects. This is caused by
incorrect x-ray beam angulation in the vertical
plane. If the PID is over angulated or too
steep relative to the long axis of the teeth a
foreshortened image will be produced. With the
Proximal overlapping is yet another form of

shape distortion that occurs in the horizontal
plane. It widens structures and superimposes
proximal surfaces onto each other. To open the
interproximal contacts between adjacent teeth,
9
Figure 7. Overlapping is an error in horizontal

angulation that widens structures and superimposes
proximal surfaces onto each other.
Figure 8a. Cone cuts are the result of improper

centering of the x-ray beam over the receptor. A
white zone is produced in the region of the receptor
where no x-rays were received. In this instance, a
rectangular cone cut occured.
the horizontal angulation of the x-ray beam

needs to be parallel to the teeth and receptor.
This directs the x-rays through the contact
points of the teeth and at a right angle to the
teeth and receptor. If the overlaps are larger in
the posterior half of the image, the horizontal
angulation was angulated too much from the
mesial toward the distal. The reverse is true for
an image in which the overlaps are larger in the
anterior half of the image. Important information
about interproximal caries and alveolar bone
levels can be obscured when contacts are
overlapped and a retake is often indicated when
overlapping is present. This error is corrected
by directing the x-ray beam through the proximal
contacts with the open end of the PID parallel to
the buccal surfaces of the teeth.
Figure 8b. Round cone cut.
can use facial landmarks or use their fingers to

extend the PID and check for proper coverage.
If the PID is not centered over the receptor, the

x-ray beam will not uniformly expose it and the
portion outside of the PID will be cut (missing).
The unexposed area will be completely white
and follow a curved border if the collimator was
round and linear if rectangular. (Figures 8a and
8b) Cone cuts occur frequently with tab bitewing
techniques when the clinician fails to align the
central ray to the center of the receptor. The
clinician tends to lose sight of the tab when
the patients mouth closes. Images with cone
cuts should be repeated if the information is not
viewable on any other projection. Typically, there
is sufficient anatomic repetition in a full mouth
survey such that one cone cut does not usually
require a retake. When taking bitewings, the
clinician should ask the patient to smile in order to
view the bite tab to aid alignment. The clinician
If the receptor is positioned incorrectly in the

patients mouth, the resulting image will not cover
the required structures. Receptor placement
can result in several types of positioning errors,
including crowns or apices cut off or improper
location. When crowns are cut off, the periapical
regions are adequately seen but details of the
tooth crowns are missing. The operator should
place the bite block of the instrument on the
incisal or occlusal surface with at least 1/8 inch of
the receptor beyond the incisal or occlusal aspect
of the teeth. Crowns can be cut off due to overangulation or image foreshortening in which the
crowns are projected off the receptor. In addition,
rigid receptors have a small periphery of dead
space which needs to be considered in receptor
placement. To avoid cutting the apices off, the
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Exposure Errors
Most dental x-ray machines compatible
with digital intraoral radiography have fixed
kilovoltage and milliamperage controls, leaving
exposure time as the only adjustable variable.
The time must be set for each periapical and
bitewing to accommodate the different thickness
in structure from one location to the next and
to maintain even image density throughout
the survey. Some manufacturers provide two
kilovoltage settings, 60 kVp or 70 kVp, which
allows the clinician to adjust contrast or the
differences in darkness. Exposure time is the
most common variable. It allows the clinician
to change or adjust density or overall darkness
on a radiographic image, but does not affect
contrast. Digital systems with automatic
exposure correction minimize exposure
variations that result in overly light or dark
images.
Figure 9a. A variety of placement errors can occur

in intraoral imaging. In this instance, the apices were
cut off.
An underexposed image will be light or low in

density and have less detail than a correctly
exposed radiographic image. Underexposure
occurs when the operator selects mA, kVp or
exposure time too low or when the patients
overall size and structural thickness are not
considered. An underexposed image cannot be
effectively improved by enhancement because
all of the x-rays did not reach the receptor
to form the image. As a result, a retake will
be necessary to achieve a diagnostic level
of density and contrast. It is the clinicians
responsibility to accurately evaluate patient size
and select proper exposure factor settings for
each area to produce an optimal image and
avoid retakes.
Figure 9b. The molar periapical was placed too far

forward and cut off the distal apex of the second
molar.
clinician must place the instrument bite block in

contact with the teeth being imaged. (Figure9a)
The patient must be instructed to bite with
enough pressure to hold the biteblock in place.
If the patient finds the biteblock and the receptor
uncomfortable, the clinician must either reposition
the receptor more lingual to the structures or use
a tissue cushion to reduce discomfort. At the
same time, the clinician must maintain the correct
placement to cover the desired structures. The
clinician must remember that each periapical
and bitewing in a survey has a particular location
with specific teeth and area requirements. In
complete or full mouth surveys, all apices, crowns
and interproximal surfaces should be displayed
when the composite views are assembled
together. Close attention to placement and
location details are necessary to produce a
comprehensive, diagnostic survey. (Figure 9b)
An overexposed radiographic image will be too

dark or high in density and difficult to discern
detail because the structures are burned out.
Overexposure occurs when the operator selects
mA, kVp or exposure time that are too high or
when the patients overall size and structural
thickness are not considered. An overexposed
image can be effectively improved by subtracting
density from each pixel, except when the
receptors are oversaturated by extremely
high levels of radiation. It is the clinicians
responsibility to accurately evaluate patient
size and select proper exposure factor settings
11
for each area to produce an optimal image and

reduce unnecessary patient exposure.
As a result, no x-rays were able to penetrate the

structures and produce an image on the receptor.
Double exposures occur when the same plate

receptor is used twice during the survey. This
can occur if the clinician confuses an exposed
plate with an unexposed plate and places it back
into the patients mouth. The scanned image will
demonstrate a dark image with superimposed
structures and an unexposed plate with no image.
Retakes are almost always necessary because
of the structural superimpositions and overly dark
image. This error can be avoided if the clinician is
organized and keeps exposed plates separated
from unexposed plates. In addition, plate
receptors must be erased with white light before
re-use to avoid a remnant image left on the plate.
Double exposures cannot be produced with rigid
digital receptors.
Backwards placement causes a blank or white

image as the result of exposing the wrong side
of the digital receptor. X-ray interaction with the
exposure side is necessary for image production.
For plate receptors, the emulsion side must be
directed toward the source of radiation and for
rigid digital receptors the plain non-wired or nonbattery side of the receptor must be directed
toward the x-ray source. (Figures 10a and 10b)
Miscellaneous Errors
Motion unsharpness can occur if the patient,
tube head or receptor moves during the exposure
producing a blurred image. Motion unsharpness
is most typically caused by patient movement.
The patient must understand and be able to hold
completely still until the exposure is complete.
These images should be retaken unless the
patient is not able to cooperate or unless the
tubehead is unstable and needs to be serviced.
Non-exposure is when a blank or white image

is produced as a result of not exposing the
digital receptor or failure to align the PID over
the receptor. Some direct digital systems have a
fixed time interval during which the receptor must
be exposed. Failure to execute the exposure in a
timely manner may also produce a non-exposure.
Creasing, crimping or bending of plate receptors

prior to exposure and scanning will produce
permanent scars on the plate and artifacts on
Figure 10a. The exposure side of the

receptor must be directed toward the x-ray
source to record a digital image. Rigid
receptor: exposure side on top; non-exposure
side on bottom.
Figure 10b. Plate receptor: exposure side on

top; non-exposure side on bottom.
12
the resultant image. These scars appear as white

lines or scratches across the image. In addition,
plate scratches can occur from rough or improper
plate handling or scanning techniques. Plate
bends or scratches produce permanent artifacts
and require plate replacement. Therefore, do
not bend the corners of the plate and handle the
plate surface carefully. There are commercial
products available to cover or cushion the corners
of the receptor to soften the edges and to avoid
bending.
degree to which an oral prosthesis interferes with

diagnostic quality depends on its type, location,
composition and how much it attenuates the x-ray
beam. An intraoral prosthesis with a metallic
baseplate will completely obscure structures
of interest and render the image useless. A
prosthesis that covers the area of interest should
be removed, but it can be used in opposition
when taking images of the opposing arch. This
facilitates proper biting and receptor stabilization.
In addition, eyeglasses, large earrings and
some facial piercings can produce foreign object
artifacts if they are between the x-ray source and
image receptor. These should be removed prior
to receptor exposure.
If the patient has oral prostheses or other types

of foreign objects, they should be removed
prior to taking any radiographic images. The
Table 1. Summary of Intraoral Image Errors.
13
Digital Panoramic Imaging
beam is penetrating through both sides to image

one. The clinician must consider the overall
patient size and the head in particular. When the
settings are off significantly in either direction, the
result will be substandard and a retake is likely.
Some systems have automated exposure controls
that modulate exposure via radiation sampling
or head measuring techniques to help avoid
exposure errors.
As with digital intraoral radiography, panoramic

images can be acquired using direct or indirect
digital imaging systems. Digital panoramic
imaging utilizes either linear array CCD or CMOS
detectors or PSP receptors. With CCD or CMOS
extraoral imaging, conventional film is replaced
by a long, vertical, rigid digital receptor a few
pixels wide. With PSP receptors, the plate is
configured in the same dimensions as panoramic
film and can be placed directly into the cassette
without the intensifying screens. As with intraoral
digital imaging, a patient file must be created,
the appropriate template or projection selected,
patient positioned, exposure made and image
viewed on the monitor. With PSP receptors, the
plate needs to be scanned before the image can
be viewed. The technique for preparing and
positioning the patient is the same as film-based
panoramic radiography. Errors can be produced
when the patient is improperly prepared, the head
alignment is incorrect and the exposure factors
are not properly selected. The quality of the
resulting image is ultimately the responsibility of
the clinician and effective application of panoramic
imaging techniques. In panoramic imaging, the file
size is considerably larger than intraoral imaging
and must be reduced by compression techniques
that facilitate storage without compromising the
diagnostic quality of the image.
Focal Trough
The focal trough, or image layer, is located
between the x-ray source and the receptor. It has
a horseshoe-shaped configuration theoretically
designed to conform to the average jaw
size. Accurate patient positioning is critical to
obtaining an optimal result. Occasionally, there
is a mismatch between a patients jaw and the
predetermined form of the image layer. Image
distortion occurs when structures are positioned
anterior or labial (narrows and blurs), posterior or
lingual (widens and blurs) or a combination of the
two relative to the focal trough. (Figure 11a) If
structures are positioned anterior or labial to the
focal trough, they will be closer to the receptor
while structures posterior or lingual to the focal
trough will be closer to the x-ray source. These
misalignments produce characteristic image
distortion patterns that, once recognized, assist
the clinician in the identification and correction of
errors. (Figure 11b)
Basic Principles of Panoramic Imaging

Panoramic imaging is based on a combination of
tomography and slit beam radiography which blurs
out some structures so others can be recorded.
This involves simultaneous rotation of a slit beam
x-ray source and the image receptor in opposite
directions. The side closest to the receptor is
recorded while structures on the opposite side are
blurred out of focus. The x-ray source is fixed at
a -10 angle and has a vertical slit aperture that
rotates behind the patients head in a lingual to
labial direction. The same exposure factors are
used as in intraoral radiography, but in panoramic
imaging the time is fixed and the kVp and mA are
variable. Each manufacturer provides guidelines
for patient exposure parameters. Generally, the
larger the individual is, the higher the kVp and
mA settings and vice versa. Kilovoltage controls
the penetrating power of the x-ray beam and the
milliamperage controls the number of x-rays that
are generated. One must remember that the x-ray
Patient Preparation and Positioning

The first step in patient preparation is to explain
the procedure and elicit patient cooperation. The
clinician must direct the patient to remove oral
prostheses, earrings, hearing aids, eyewear,
facial and oral piercing jewelry, napkin chains and
necklaces before making a panoramic exposure.
The clinician should follow the established safety
protocols of the dental office which may include
the placement of a panoramic protective apron
(without a thyroid collar). The apron must fully
clear the back of the neck region; be high in
front, low in back. Placement of the protective
apron too high on the back of the patients neck
or bunching it at the shoulders will produce a
protective apron artifact on the image. When
positioning patients for panoramic imaging,
manufacturers directions should be followed
closely, as each panoramic machine is slightly
different. In general, patients should be seated or
14
Figure 12a. Proper head alignment.

Midsagittal plane is centered and aligned
perpendicular to the floor.
Figure 11a. In panoramic imaging, improper

patient alignment produces characteristic
image distortion patterns. Misalignment in
the AP plane either narrows or widens the
structures when positioned outside the focal
trough.
Figure 11b. Misalignment in the midsagittal

plane produces narrow structures on one side
and wide structures on the other.
Figure 12b. Frankfort plane is aligned

parallel to the floor.
stand erect with the cervical spine as straight and

as centered as possible. The patients midsagittal
plane should be aligned perpendicular to the
floor and the Frankfort plane aligned parallel to
the floor. (Figures 12a and 12b) The patients
teeth should be biting end-to-end in the biteblock
groove with the anteroposterior (AP) light aligned
with a specific anatomic landmark. Typically, the
AP landmark is in the canine tooth or contact
on either the maxilla or mandible, or aligned
with the nasolabial fold for edentulous patients.

(Figure12c)
Criteria for a Diagnostic Panoramic

Image
How do you know when you have a quality

image? You can compare your result with the
following criteria. A diagnostic panoramic image
should display the following features:
15
The image is free of technical, patient

preparation and exposure errors. (Figure 13)
Common Panoramic Errors

Alignment Errors
The diagnostic quality of a panoramic image
is largely determined by the same geometric
considerations that apply to intraoral radiographic
images: the relative position of the patients
jaws, teeth, x-ray beam and receptor. The
consequences of malpositioning and
misalignment are as equally problematic with
panoramic images as they are with intraoral
images.
Midsagittal Plane Errors If the patients head
is tilted, the image will appear crooked or skewed
diagonally across the image. One condyle will
be higher than the other, the occlusal plane will
appear crooked and distortion of teeth will be
observed right to left. (Figure 14) If the head
is rotated or turned to one side, the result will
be under magnification of the side toward the
receptor and over magnification of the side
toward the x-ray source. One side appears
narrowed and the other side appears widened.
These errors present unequal right to left
distortion. None of the recorded structures are
the correct dimension particularly in the horizontal
plane. (Figure 15)
Figure 12c. AP plane is aligned with specific

anatomic landmark.
The entire maxilla and mandible are recorded,

including the temporomandibular joints.
As patient anatomy allows, structures are
displaced symmetrically on both the right and
the left sides of the image.
A slight smile or downward curve of the
occlusal plane is evident.
The image demonstrates good representations
of the teeth with minimal under or over
magnification.
The patients tongue was in place against the
hard palate during exposure, eliminating the
palatoglossal airspace.
The patients lips were closed during exposure
avoiding burn-out of the anterior teeth crowns.
Minimal or no cervical spine shadow is visible
and the anterior teeth are clearly seen.
The image displays acceptable levels of
contrast and density.
Vertical Head Errors If the patients head is

tilted too far downward, not aligning the Frankfort
plane, the arches will appear constricted. The
condyles will appear closer together and may
be cut off the top of the image. The overall
appearance will be that of a Jack-O-Lantern
Figure 13. This is an example of a radiographic image that meets the criteria for
a diagnostic panoramic.
16
Figure 14. Panoramic image demonstrating a midsagittal head tilt. Note the
crooked display of the occlusal plane and widened structures on one side and
narrow structures on the other.
Figure 15. Panoramic image with a midsagittal head turn or rotation. Note the
structures are distorted right to left with one side narrowed and the other side
widened.
Figure 16. The head is tilted downward on this panoramic image which
demonstrates an exaggerated grin with blurred, foreshortened lower anterior teeth.
grin due to the accentuated Curve of Spee. In

addition, the lower anterior teeth are positioned
lingual to the focal trough and appear blurred,
widened and foreshortened. (Figure 16) If the
patients head is tilted too far upward, superior
structures will be placed lingual to the focal
trough. The image of the arches will be one of

overall occlusal flattening and elongation of the
maxillary teeth. The general appearance is that
of a frown configuration of the Curve of Spee.
The condyles will be farther apart and may be
cut off the sides of the image. The orbital and
17
Figure 17. The head is tilted upward on this panoramic image which displays
frown configuration with blurred, elongated upper anterior teeth. Note hard palate
superimposition over maxillary teeth apices and distorted nasal cavity structures.
Figure 18. On this panoramic image, the head was positioned too far forward
which most noticeably narrows both the maxillary and mandibular anterior teeth.
Also note evidence of a slight head tilt.
Cervical Spine Slump When the patients

cervical spine is slumped forward, instead of
remaining perpendicular to the floor, it is then
positioned too far anteriorly. The vertebrae are
projected more visibly on the lateral borders of
the image and obscure the anatomic structures
of the ramus. The cervical vertebrae become
compressed, block passage of the x-ray beam
and produce a column or triangular-shaped
midline radiopacity that obscures the anterior
teeth and adjacent structures. (Figure 20)
nasal structures will be out of focus and the hard

palate superimposed over the maxillary teeth.
(Figure17) These errors present alterations
particularly in the configuration of the occlusal
plane and involve one arch or the other.
Anteroposterior Errors If the patients head
is positioned too far forward, the anterior teeth
will be labial to the focal trough and will appear
blurred and narrower than the actual objects.
Overlapping of the contacts will be evident and
often superimposition of the spine onto the rami.
(Figure 18) Conversely, if the patients head is
too far back, the anterior teeth will be lingual to
the focal trough and appear blurred and wider
than the actual objects. Excessive ghosting
of the opposite mandible and condyles cut off
the sides accompany distortion of the teeth.
(Figures 19a and 19b) These errors present
width alteration involving both the maxillary and
mandibular anterior teeth.
Motion Unsharpness Vertical, horizontal or

compound patient movements can produce
artifacts on panoramic images. With intraoral
projections, motion produces generalized
unsharpness; with panoramic projections, motion
unsharpness only affects the portion of the
image being exposed at the time the movement
occurred. Therefore, depending on the extent
and duration of movement, only a portion of
18
Figure 19a. On these panoramic images, the head was positioned too far back or
lingual to the focal trough. This image demonstrates some anterior widening and
ghosting of the opposite mandible.
Figure 19b. Extreme example of AP malpositioning with excessive ghosting of the

opposite ramus and spine and cut-off condyles. Note head is tilted upward as well.
Figure 20. When the cervical spine is slumped, a triangular radiopacity is created
in the midline which can obscure the anterior structures. Also, note a midsagittal
positioning error as well.
19
Figure 21a. Movement produces motion unsharpness in the plane of the head
movement. Vertical head movement up and down produces spikes and blurred
structures in the areas of movement.
Figure 21b. Horizontal movement of the head to one side blurs the structures in
the area of movement. This may occur concomitantly with shoulder contact.
the exposure may be blurred while the rest

of the image is within acceptable limits. Very
short-duration movement may be difficult to
detect because the resulting artifact can look
suspiciously like a pathological condition such
as a healed fracture. Generally speaking, the
artifact reflects the plane in which the movement
occurred.)
clinician should plan ahead and have strategies

for handling these problems. If the patient is
able, instructing them to lower their right shoulder
down during machine rotation may solve the
problem. Other strategies include having the
patient bend the right knee to lower the entire
right side, instructing the patient to hold the
handlebars underhanded or cross-handed rather
than over-handed or seat the patient so their
hands and arms can hang down on the side
to bring their shoulders down. Sometimes a
combination of these strategies is effective as
well. Other obstacles may include fixed, slumped
spines and Dowagers hump anatomy. If the
source and receptor fail to rotate, only a portion
of the jaw will be imaged instead of the entire jaw.
Occasionally, motion unsharpness occurs in the
horizontal plane if the shoulder is bumped without
prior warning. Unfortunately, some patients
Shoulder Interference Panoramic imaging

involves a complex series of coordinated,
simultaneous movements. Because of this,
mechanical errors can affect the acquisition and
quality of the image. One of the most common
obstacles to smooth rotation is contact with the
patients shoulders. The clinician must take into
consideration the neck and shoulder anatomy
of the patient. If the patients neck is short and
thick with heavy shoulders, contact is likely. The
20
Figure 22a. Ghost images of the opposite ramus appear bilaterally on this
edentulous panoramic image. Note evidence of a slumped cervical spine in the
midline.
Figure 22b. Ghost images of hoop earrings are displayed on this panoramic
image. Note presence of head tilt and head up alignment errors.
just dont fit into the machine properly so an

alternative imaging technique such as the lateral
jaw technique may be employed to accommodate
those patients.
1. They are projected onto the side opposite to

the original object.
2. The image is reversed compared to the
original object.
3. The ghost appears higher in position than the
original object.
4. The ghost image appears magnified and
unsharp in the horizontal plane.
Imaging Errors
The degree to which a panoramic image blurs
out objects outside the focal trough is dependent
on how dense those objects are. Ghost images
are remnant images from the opposite side of
structures or objects that cannot be completely
blurred out of focus. Some ghost images are
inherent in panoramic imaging, but others can
be completely avoided. Although a number of
objects can produce ghost images, the most
common ghost images are the angle and ramus
of the mandible and earrings, or the like, not
removed prior to exposure. (Figures 22a and 22b)
Ghost images have particular characteristics and
can be recognized by the following features.
Other avoidable artifacts include the palatoglossal

airspace and open lips, both of which produce
radiolucent areas that interfere with interpretation.
To avoid the palatoglossal airspace artifact, the
patients tongue must be held against the palate
during exposure. If the clinician fails to give this
instruction, the air space between the tongue and
the hard palate will produce a radiolucency above
the apices of the maxillary teeth. (Figure 23)
Similarly, the patients lips should remain closed
to avoid burnout of the anterior teeth crowns.
21
Summary
increase radiation exposure to the patient. With

proper patient preparation, optimal techniques
and attention to detail, the clinician can provide
the dental team with diagnostic intraoral and
panoramic images that permit proper diagnosis
and treatment of patients.
The goal of the clinician should be to produce

a quality radiographic image the first time. A
substandard radiographic image is worse than
no image at all because it does not provide the
necessary diagnostic information and retakes
Figure 23. The bat-shaped radiolucency above the maxillary teeth crowns is
the palatoglossal airspace. To avoid this artifact, direct the patient to press the
tongue against the roof of the mouth during exposure. Note error in forward AP
alignment as well.
22
Table 2. Summary of Panoramic Image Errors.
23
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce462/ce462-test.aspx
1.
When retaking this bitewing, the clinician would to correct the error
displayed on this image.
a.
b.
c.
d.
2.
The clinician failed to
a.
b.
c.
d.
3.
center x-ray beam over the receptor

change the horizontal angulation
place the receptor more apically
increase the vertical angulation
and that resulted in this periapical image error.
ask the patient to remove the maxillary partial denture

direct the horizontal angle through the teeth contact points
selected an exposure time setting too low for posterior teeth
use the correct vertical angulation to control shape distortion

is most likely eliminated by use of a receptor instrument with an x-ray
beam guide ring.
a. Cone cutting
b. Overexposure
c. Proximal overlap
d. Placement error
24
4.
When retaking this periapical radiograph, the clinician would have to

to avoid the same mistake.
a.
b.
c.
d.
5.
center the x-ray beam over the receptor

placement the receptor in the correct location
instruct the patient to hold still during exposure
increase the exposure time setting on the machine
a.
b.
c.
d.
best describes the image error recorded on this periapical view.
Image foreshortening
Horizontal overlapping
Underexposure to x-rays
X-ray beam not centered
6.
The vertical angulation controls the
7.
8.
When the clinician is using the bisecting angle technique, the central ray is directed at a right
angle to the .
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
length of the structures

centering the x-ray beam
placement of the receptor
proximal entry of the x-rays
most effectively controls shape distortion.
Size of the focal spot

Source to object distance
Object to receptor distance
Object-receptor parallelism
long axis plane

image receptor
dividing plane
teeth crowns
25
9.
Each of the following items would produce image elongation except

a.
b.
c.
d.
under angulation in the vertical plane

curvature of a phosphor plate receptor
diagonal alignment in the horizontal plane
alignment with the tooth in bisecting technique
10. When determining the exposure time for intraoral imaging, the clinician should take into
consideration whether it is .
a.
b.
c.
d.
posterior or anterior area

dentate or edentulous
child or adult patient
all the above
11.
a.
b.
c.
d.
would correct the image error recorded on this dental image.
Decrease the positive vertical angle of the PID

Direct the central ray toward the middle of the receptor
Position the receptor in the mouth to cover the required teeth
Direct the horizontal angulation through the contacts of the teeth
12. If the apices are cut off on a periapical image,

a. foreshortening
b. receptor placement
c. horizontal overlapping
d. improper beam centering
was the most likely cause.
13. If the patients head was aligned as shown in this picture,

evident on the resultant panoramic image.
a.
b.
c.
d.
would be
frown appearance of the occlusal plane

one side wider, the other side narrowed
anterior teeth appear blurred and widened
condyles would be cut off the top of the image
26
14.
to avoid the radiolucent artifact above the maxillary teeth as demonstrated
on this panoramic image.
a.
b.
c.
d.
Direct the patient to stand with an erect spinal column

Tell the patient to press the tongue against the palate
Align the midsagittal plane perpendicular to the floor
Have the patient bite end-to-end in the bitepiece
15. Errors in the midsagittal head plane are characterized by distortion that involves
.
a.
b.
c.
d.
the entire dental midline

either the maxilla or mandible
one side narrow, the other side wide
maxillary and mandibular anterior teeth
16. Each of the following selections is correct about panoramic imaging except the
a.
b.
c.
d.
patients head aligned according to anatomical planes

side closest to the receptor is the one recorded in focus
x-ray beam travels labial to lingual just like intraoral imaging
x-ray head rotates behind the head and the receptor in front
17. In panoramic imaging, each of the following must be removed prior to patient positioning and
exposure except a .
a.
b.
c.
d.
hearing aid
plastic head band
metal tongue ring
patient napkin chain
18. If a panoramic radiograph exhibits an irregular pattern of the lower border of the mandible,
this is most likely due to .
a.
b.
c.
d.
patient head movement

receptor not moving freely
tongue not placed in palate
exposure button let go too soon
19. When the patient is positioned posterior or lingual to the focal trough, structures will appear

.
a. shortened
b. narrowed
c. widened
d. crooked
27
20. Each of following is a criterion for a diagnostic panoramic image except
21. Each of the following errors is present on this panoramic image except a
a.
b.
c.
d.
a.
b.
c.
d.
a slight smile or downward curve of the occlusal plane

the maxilla, mandible, temporomandibular joints recorded
a clear view of the interproximal surfaces of all of the teeth
a symmetrical display of the anatomic structures right to left
protective apron too high on neck

slumped cervical spine
head is tilted upward
midline is off-center
22. When the patients head is positioned too far backward in panoramic imaging, the clinician
may observe all of the following manifestations except .
a.
b.
c.
d.
excessive ghosting of the spine and mandible occurs

the image is enlarged and the condyles are not recorded
the occlusal plane has a diagonal or crooked appearance
the structures appear wide and blurred compared to normal
23. The
this panoramic image.
was improperly aligned such that it caused the problem evident on
a. Frankfort plane
b. midsagittal plane
c. anteroposterior plane
d.cervical spinal column
24.
causes superimposition of the hard palate over the apices of the maxillary
teeth on a panoramic image.
a.
b.
c.
d.
Patients head forward

Cassette placed too low
Patients head is too high
Head rotated to one side
28
25.
a.
b.
c.
d.
Patients
Patients
Patients
Patients
caused the distortion apparent on this panoramic image.
head
head
head
head
tilted too high up

tilted too far down
is positioned too far back
is turned toward one side
29
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13. Parks ET, Williamson GF. Digital radiography: An overview. J Contemp Dent Pract. 2002 Nov
15;3(4):23-39.
14. ScanX Digital imaging system in-line erase. Instruction manual. Air Techniques, Inc. Melville, NY,
2012. Accessed March 18, 2013.
15. Scarfe WC, Williamson GF. Practical panoramic radiography. Online Continuing Education Course.
Dental ResourceNet. Procter & Gamble Company, Cincinnati, Revised, 2011.
16. Versteeg CH, Sanderick GC, van Ginkel FC, van der Stelt PF. An evaluation of periapical
radiography with a charge-coupled device. Dentomaxillofac Radiol. 1998 Mar;27(2):97-101.
17. Williamson GF, Parks ET. Digital radiography: A new technology for dental imaging. Access
2006;20:15-19.
18. Williamson GF. Better techniques, better radiographs. J Prac Hyg 2003;12:10-15.
19. Williamson GF. Digital radiography in dentistry: Moving from film-based to digital imaging.
American Dental Assistants Association, Chicago, 2004.
20. Yoshiura K, Nakayama F, Chikui T, et al. Effects of the automatic exposure compensation on the
proximal caries diagnosis. Dentomaxillofac Radiol. 2005 May;34(3):140-4.
30
About the Author

Gail F. Williamson, RDH, MS
Professor
Department of Oral Pathology, Medicine & Radiology
Indiana University School of Dentistry
Gail Williamson received an AS in Dental Hygiene, a BS in Allied Health and a
MS in Education from Indiana University. A veteran teacher, Prof. Williamson has
received numerous awards for teaching excellence during her academic career. She
is a published author and presents continuing education courses on topics in Oral and Maxillofacial
Radiology nationally.
Email: gwilliam@iu.edu
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Digital Imaging Techniques and Error Correction

Gail F. Williamson, RDH, MS

Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce462/ce462.aspx

Conflict of Interest Disclosure Statement

The author reports no conflicts of interest associated with this work.

The Procter & Gamble Company is an ADA CERP Recognized Provider.

Crest + Oral-B at dentalcare.com Continuing Education Course, December 9, 2014

Approved PACE Program Provider

on the energy of the x-ray beam and composition of

absorption - transfer of some or all of x-ray

brightness - digital equivalent to density, or overall

Crest + Oral-B at dentalcare.com Continuing Education Course, December 9, 2014

cassette - a metal, plastic or cardboard light-tight

double exposure - a radiographic image that has

charge coupled device (CCD) - solid-state,

electron well - individual pixel into which x-ray or

collimation - device used to restrict the size and

elongation - image distortion in the vertical plane

emulsion - plate receptors have a crystalline

complimentary metal oxide sensor active pixel

exposure time - regulates the period of time over

compression - computer methods used to

focal spot - anode tungsten target where x-rays

contrast - the difference in densities between

focal trough - area or zone of sharpness in

density - overall degree of blackness or image

foreshortening - image distortion in the vertical

diagnostic - radiographic image that properly

Frankfort plane - used to align the vertical plane of

digital image a video image in pixel format

ghost image - an artifact produced in panoramic

digitization - conversion of an incoming analog

gray level - measure of image brightness or

Crest + Oral-B at dentalcare.com Continuing Education Course, December 9, 2014

horizontal angulation - movement of the x-ray

marginal - radiograph that may be adequate and

image enhancement - image processing

milliamperage (mA) - regulates the low voltage

image matrix - layout or grid of pixels in rows

non-diagnostic - radiographic images in

interproximal - the areas between teeth in the

overexposure - a radiographic image that is too

kilovoltage (kVp) - regulates the high voltage

photostimulable phosphor plate (PSP) - digital

latent image - the energy stored in a receptor

photomultiplier tube - electron tube that converts

linear array - solid-state detector that consists

pixel - picture element; individual cell of the image

lossy - storage method in which some data is

positioning indicating device (PID) - device

lossless - storage method in which no

radiopaque - light or white areas on the

Crest + Oral-B at dentalcare.com Continuing Education Course, December 9, 2014

Random Access Memory (RAM) - temporary

vertical plane - movement of the x-ray head and

receptor - any device or medium that transforms

XCP (eXtension Cone Paralleling) - a receptor

resolution - measures how well a radiographic

Digital radiographic imaging in dentistry is nothing

sensor - a receptor device used in digital

Digital Intraoral Imaging Overview

underexposure - a radiographic image that is too

Prior to the acquisition of intraoral digital images,