Assembly and clinical use of the XCP dental x-ray film holder

orientation devices in dentistry.

Abstract

XCP dental x-ray film positioning devices help to increase the

dimensional accuracy of dental x-ray images. (XCP stands for

"extension cone paralleling." Some dental assistants refer to

them as "Rinn" devices, after a company that manufactures

them.) The XCP device has a collimator ring that is parallel with the

film--holding plane of the x-ray film holder. This positioning helps an

assistant to align the plane of the unseen, intraorally located x-ray

film parallel with the plane of the cross section of the x-ray beam. XCP

devices also help to prevent dental x-ray film cone cuts, since the

extraoral collimator ring helps to indicate the boundary of the unseen

x-ray film. Unfortunately, the devices can be confusing to assemble

because each device consists of three pieces that can be assembled in

multiple ways, and there are three types of such devices for anterior,

posterior and bitewing radiographs (in addition to a fourth accessory

device for taking endodontic radiographs). It can be challenging to

determine which piece goes with which type of XCP, and to choose the

correct XCP assembly for taking a desired x-ray. This article describes

some clinical techniques of assembling XCP radiographic film-holding

devices, describes the clinical use of XCP devices, and ways of

overcoming intraoral obstacles to device placement.

**********

The XCP film holder consists of three parts: a film-holding piece

with two fused planes angled at 90 degrees to each other, a large round

collimator ring and a metal rod that connects the ring with the film

holder (Figure 1, page 10). One plane of the film-holding piece contains

a slot in which the x-ray film is inserted, while the other plane serves

as a platform on which the patient bites down. This platform also

contains the insertion holes for the prongs of the metal rod to insert

into to connect the collimator ring with the film-holding piece. The

collimator ring itself contains a slot which slides into the side of the

metal rod that is opposite the side containing the prongs. Sliding the

ring along the rod brings the ring as dose to the patient's cheek

as possible. This allows the opening of the x-ray tube, placed up

against the collimator ring, to be as close to the film as possible. The

plane of the collimator ring is parallel with the plane of the

film-holding piece.

If the film is completely flat against the plane of the

film-holding piece, the film itself will be parallel to the plane of the

collimator ring. Although the film itself is located intraorally and is

difficult to see, the collimator ring is located extra-orally when the

assembled XCP is placed in the patient's mouth because lining up

the plane of the opening of the x-ray tube with the plane of the

collimator ring will also align the plane of the x-ray tube opening

parallel with the plane of the x-ray film. When the film is placed in

the film holder, the side of the film facing the collimator ring (and

consequently the x-ray beam) must be the white exposure side of the

film. This also orients the film packet such that the convex side of the

orientation dimple on the film faces towards the x-ray tube. This way
looking at this convex side on the resulting developed film is the same

as looking directly at the patient from in front of the patient.

The following explains the assembly and use of XCP devices, but is

not necessarily a complete treatment of the topic. The reader should

consult other sources for information on taking a full mouth series of

x-rays or for specific details on techniques such as the bisecting angle

or paralleling techniques) (1-3)

General procedure for assembling the XCP

A suggested approach to assembling the XCP is to start assembling

it by correctly orienting the film holder, given the tooth that the

dentist wants to image. A correctly oriented film holder serves as a

fixed reference in space for guiding the addition of the metal rod to

the film holder. After adding the metal rod to the film holder, the

assistant adds the collimator ring to the metal rod, using both the rod

and the film holder as fixed references for properly orienting the

collimator ring. It may be confusing to try to orient the metal rod or

the collimator ring in three-dimensional space without first

establishing the film holder as a fixed reference.

Orienting the film holder

The plane of the film holder that holds the film is always located

intraorally, lingual to the teeth being imaged. The other plane of the

film holder--containing the insertion points for the metal prongs--is

placed between the teeth, which occlude into that plane. If the film

holder is incorrectly oriented, the rest of the XCP assembly will be

incorrect (Figure 1, below).

Adding the metal rod to the correctly oriented film holder

The prong end of the metal XCP rod fits into the insertion points

in the film holder located at the vicinity of the mouth opening. The

other (non-prong) end of the metal rod is always located outside of the

mouth. If the metal rod has a 90 degree bend to it, the bend is always

positioned outside of the mouth opening. The metal rod is always placed

so that no part of the metal is between the x-ray beam and the film.

[FIGURE 1 OMITTED]

Adding the collimator ring to the metal rod

After correctly combining the film holder and the metal rod, the

assistant attaches the collimator ring to the rod. The assistant slides

the ring

onto the rod by inserting the rod through the hollow square opening

on the collimator ring. The orientation of the round collimator ring is

correct when the film (when it is placed in the film holder) appears

centered within the round collimator when looking through the round

collimator. That is, the left and right sides of the film are both an

equal distance to the perimeter of the collimator ring, and the top and

bottom sides are both an equal distance to the perimeter of the

collimator ring.

[FIGURE 2 OMITTED]

Distinguishing between XCP film holders

The bitewing film-holding plane has two film-holding slots on it

and attaches at its midline to the plane that contains the metal prong

insertion holes. The film-holding plane of the posterior film holder is

wider than the plane that has the metal prong insertion holes. The two
planes of the anterior film holder are approximately the same width and

look thinner than the posterior film holder planes.

Distinsuishing between XCP metal rods

The bitewing metal rod is straight with no bends, while the

posterior metal rod has one 90 degree bend. q-he anterior metal rod has

two 90 degree bends that lie on two different planes. The bitewing and

posterior metal rods are two-dimensional so that they both lie flat when

placed on a flat plane like a tabletop. The anterior metal rod is three

dimensional and does not lie flat when placed on a tabletop (Figure 2,

above).

Assembling the anterior XCP

There is only one correct assemblage of the anterior XCP, and this

assemblage allows one to image all anterior teeth. The film holder is

placed so that the incisor edges occlude towards the edge of the plane

containing the insertion holes for the prongs of the metal rod. When

imaging the maxillary anteriors, the metal rod is oriented in the XCP

assemblage so that one 90 degree bend of the metal rod is located at the

level of the film holder, while the other bend is located interior to

the film holder.

Ideally, when imaging the maxillary anteriors, there is enough

palate space intraorally so that the superior edge of the x-ray film can

be placed without imping-ing on the palate. Such impinging can bend the

superior aspect of the film and deflect the film so that it is not

parallel to the maxillary anterior incisors.

When placing the anterior XCP for imaging the anterior mandibular

indsors, ideally there is enough clearance at the floor of the mouth and
the film does not press with excessive force into the lingual frenum. A

pediatric-sized x-ray film can be used to reduce interference with the

floor of the mouth. The assistant typically aims to have the

patient's incisal edges bite dose to the anterior edge of the film

holder, since this will allow the plane containing the film to be placed

as far posteriorly as possible, which tends to put it out of contact

with the lingual aspect of the mandibular arch or mandibular tori. If

the film cannot be placed fully parallel to the teeth, the assistant

should try to angle the tube of the x-ray to accommodate for this and to

minimize distortion from foreshortening or elongation in the resultant

x-ray image.

Assembling the bitewing XCP

There is only one correct assemblage of the bitewing XCP, which

allows one to take both left and fight bitewings. The metal rod is

inserted into the film holder so that the two film-holding slots of the

film holder face away from the collimator ring. This way, the plane of

the film holder fits between the teeth and the tongue, and the teeth

occlude into the flat horizontal plane of the film holder (Figure 3,

opposite page).

The assistant orients the film so that the white side of the film

faces the flat horizontal plane of the bitewing film holder. To place

the film into the bitewing film holder, the assistant pinches the film

by squeezing its two longer sides between two fingers to form a bulge,

with the convex side of the bulge facing away from the film-holding

slots on the film-holding plane of the film holder. The assistant then

inserts one edge of the film into one of the film-holding slots, and
then inserts the other edge into the other slot.

The bitewing XCP comes with different types of film holders, one

for taking vertical bitewing radiographs, the other for taking

pediatric-sized radiographs.

An inverted way of assembling the bitewing XCP

Some dental assistants insert the metal rod into the film holder so

that the two film-holding slots face toward the collimator ring.

Technically, this bitewing XCP assemblage is incorrect, but it may

result in acceptable bitewing films. Here, the film is placed into the

film holder so that its white side faces away from the flat horizontal

plane of the film holder. When the bitewing XCP is placed intraorally,

the film holder pushes the tongue out of the way (Figure 4, lower

right).

Assembling the posterior XCP

There are two possible correct assemblages of the posterior XCP.

The assemblage that enables imaging the posterior teeth for one quadrant

will also enable imaging of the posterior teeth of the quadrant that is

diagonally opposite the first quadrant. For example, the posterior XCP

assemblage for the maxillary left posterior is also the same for the

mandibular right posterior. Likewise, the assemblage for the maxillary

right posterior is also the same for the mandibular left posterior. If

an assistant is taking a flail mouth series of x-rays, then after

imaging one posterior quadrant, the assistant should use the current

assemblage to image the opposite diagonal quadrant. In other words, the

assistant should use one assemblage to image both opposite quadrants,

instead of dis-assembling and re-assembling the posterior XCP four times

to take films of all four posterior quadrants.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

[FIGURE 6 OMITTED]

The posterior XCP also comes in a different version with a film

holder designed for taking radiographs during endodontic procedures. The

film holder has an opening in its superior aspect that allows the

assistant to place the film holder over a tooth that contains an

endodontic file without the file impinging on the film holder (Figure 5,

upper left).

Positioning the posterior XCP intraorally

When placing the posterior XCP to image the maxillary posterior

teeth, the assistant positions the superior edge of the film so that it

is coincident with the midline of the palate since the midline of the

palate has the most vertical clearance. The assistant should also ensure

that the posterior superior comer of the film does not aggressively

press into the posterior palate, or that the anterior superior comer of

the film does not aggressively press into the anterior aspect of the

palate. The film plane should be as parallel with the long axes of the

maxillary teeth as is practical.

When imaging the mandibular posteriors, the assistant should avoid

aggressively pushing the film edges into the tori, lingual borders of

the lingual arches, or floor of the mouth.

To overcome interference from tight cheek muscles, the Cosmetic dentist office assistant

can place a finger on the inside of the cheek and push the cheek out in
a lateral direction while placing the posterior XCP intraorally, such

that the entire width of the film holder fits inside the cheek (Figure

6, page 14). The patient can also be asked to dose slightly to relax the

cheek. The flabbier cheek is less obstructive to the film holder

compared to a taut cheek, which occurs when the patient is opened

widely. Once the film holder is located posteriorly, the assistant may

attempt to rotate the XCP posteriorly, towards the patient's ear,

if the assistant wants to align the collimator ring (and the x-ray beam)

with the third molar area.

One way to facilitate positioning the XCP posteriorly is to use a

pediatric-sized film instead of an adult-sized film, since the edges of

the adult film may protrude too far posteriorly compared to those of

pediatric film. The pediatric film is placed horizontally in the film

holder, so the film does not protrude much beyond the borders of the

film-holding plane of the x-ray holder. This eliminates protruding film

edges that can cause discomfort, the trade-off being that the film may

be too short to capture the root apices. Alternatively, the pediatric

film can be placed vertically in the film holder to increase the chance

of capturing the apices. Here, the film protrudes vertically, but since

it does not protrude horizontally the patient may be able to tolerate

its placement.

Using anesthesia to take posterior x-rays

Topical anesthesia or even local anesthesia maybe used to

anesthetize a quadrant to allow for placement of the XCP. If the patient

will need dental work requiring anesthesia in a quadrant that needs

x-rays, the patient can have the x-rays taken during the dental work
visit, using the same anesthesia for both the dental work and the taking

of radiographs.

Other topics

The assistant should use a relaxed grip when holding the XCP, so

that the patient can push the XCP out of the way if it is pushing into a

sensitive mouth structure while it is being placed. Final seating of the

film may sometimes be done by the patient, so that the patient can

adjust the amount of force with which the film edge is pressed into the

floor of the mouth.

To overcome a gag reflex, place a pinch of salt on the tip of the

patient's tongue. For some reason, some say this can minimize a

posterior gag reflex and facilitate film placement. A panoramic

radiograph may be taken instead of periapical radiographs if the patient

cannot tolerate deep posterior placement of the XCP.

With some creativity, an anterior XCP can be used to take

radiographs of posterior teeth, if the film is placed horizontally in

the film holder, instead of vertically as is typical when taking

anterior images with the anterior XCP. The assistant should see how the

horizontally placed film lines up with the collimator ring, and adjust

the alignment of the plane of the opening of the x-ray tube accordingly

to align it with the film. The assistant then tries to place the

anterior XCP posteriorly and hopes to not encounter much interference in

placement. Similarly, a posterior XCP can be used to take anterior films

if the film is placed vertically in the film holder.

The collimator rings for the anterior XCP and the bitewing XCP are

both similarly shaped, so the anterior XCP collimator ring can be

attached to the bitewing metal rod and be used when taking bitewing

x-rays. Similarly, the bitewing XCP collimator ring can be attached to

the anterior XCP metal rod and be used when taking anterior x-rays.

However, the posterior XCP ring is shaped specifically for the posterior

XCP and can only be used with the posterior XCP.

Newer XCP technologies

A different type of XCP device exists where the round collimator

ring contains color-coded insertion points for all three of the

posterior, anterior and brewing XCP assemblages. A single metal rod has

all three prongs (also color-coded) for the three assemblages. XCP

devices have also been developed that have film holders that accommodate

digital x-ray sensor devices. *

As a side note, a Cone Beam three-dimensional x-ray scan can be

made of a patient's head and neck area and then be used to derive a

computer-generated digital image of a two-dimensional full mouth series

for that patient. Hence, as Cone Beam 3D imaging becomes more common,

there may be less need for XCP x-ray positioning devices for taking a

full mouth series of x-rays.

* Editor's note: A more indepth article exploring the uses of

the new XCP models by Dr. Mamoun will be forthcoming in an upcoming

issue of the Journal.

(1.) Hating, Joen Iannucci, and Lind, Laura Jansen. Dental

Radiography: Principles and Techniques. 3d ed. Philadelphia, Saunders,

2005.

(2.) Whaites, E. Essentials of dental radiography and radiology.

3rd edition. Edinburgh: Churchill Livingstone, 2002.

(3.) White S, Pharaoh M. eds. Oral radiology: principles and

interpretation. 5th ed. St Louis, Mo: Mosby, 2004.

John Mamoun, DMD, is a 2003 graduate of the University of Medicine

and Dentistry of New Jersey. He completed a one-year Advanced Education

in General Dentistry residency at the Eastman Dental Center, a division

of the University of Rochester Medical School in Rochester, N.Y., and

later earned his Fellowship award from the Academy of General Dentistry.

He is currently in private practice in Manalapan, N.J. Dr. Mamoun has

published several articles in peer-reviewed dental journals and serves

as a manuscript reviewer for General Dentistry, the peer-reviewed

journal of the Academy of General Dentistry. He is currently interested

in analyzing how the use of high-magnification loupes or microscopes in

clinical practice can lead to improved diagnoses and treatments of

dental problems.