INTRODUCTION USES OF RADIOGRAPHS HISTORY FILMS & SOLUTIONS FORMATION OF IMAGE PROJECTION GEOMETRY INTRAORAL TECHNIQUES OBJECT LOCALIZATION

TECHNIQUES DIGITAL RADIOGRAPHY PANORAMIC RADIOGRAPHY SPECIALIZED RADIOGRAPHIC TECHNIQUES PERIODONTAL CONSIDERATIONS RADIATION SAFETY

Accurate & masterful interpretation of radiograph depends greatly on amount of information captured in radiograph, thus there is a direct inter-relationship between Radiographic technique & Interpretations. The intraoral radiograph, when correlated with the case history and clinical examination, is one of the most important diagnostic aids available to the dental practitioner. The activity or progression of periodontal disease can not be diagnosed by cross sectional study , similarly, outcome of treatment can not be confirmed without successive radiographic evaluation over a period of time.

Illustrate changes secondary to caries,

periodontal disease & trauma. Reveal evidence of disease that cannot otherwise be found. Confirm or classify suspected disease. Localize lesions or foreign objects. Evaluate growth or development. Document the condition of the patient at a specific point In time.

WILHLEM CONRAD ROENTGEN, Bavarian Physicist. November 8, 1895 To honor him, X-rays were referred as, Roengen Rays, radiology was referred as roengenology & radiographs were known as roengenograph. In 1838, Heinrich Geissler built First Vacuum Tube. In 1870 Johann Wilhelm Hittorf discovered Cathode rays. Vacuum tube used by Roengen incorporated best features of Hittorf & Crookes designs & known as Hittorf-Crookes Tube. Philip Lenard in 1894, was very close to discovery of X-Rays.

First dental radiograph was taken by Otto Walkhoff. C. Edmund Kells is credited with first practical use of radiographs in dentistry. William H. Rollins was the first one to develop dental X-Ray unit. Frank Von Woert was first to use Film in intraoral radiography. H. R. Raper, established first college course in radiology for dental students.

 In 1913, William D. Coolidge developed first Hot cathode X-Ray tube, which became prototype for all modern X-Ray tubes. In 1923, miniature version of X-Ray tube was developed by Victor X-Ray Corporation Later in 1933, modified version was developed by General Electric which have not changed much over the years. Machine with variable KV was introduced In the year 1957, & in 1966, a recessed long beam tubehead was introduced. From 1896 to 1913, dental X-Ray packets consisted of Glass photographic plates or films, cut into small pieces & hand-wrapped in black paper. In 1913, Eastman Kodak Co. manufactured the first prewrapped intraoral films . First machine made periapical packets became available in 1920.

C. Edmund Kells in 1896 introduced Paralleling technique, Used by Franklin W. McCormack in practical dental radiography in 1920. Gordon M. Fitzgerald in 1947 introduced Long Cone Paralleling technique. He is termed as Father of Modern Dental Radiography. Weston Price in 1904 introduced the Bisecting Technique. Howard Riley Raper redefined the original bisecting technique & introduced Bitewing technique in 1925. Yrjo Paatero & Hisatugu Numata are independently being credited with introduction of Panoramic radiography. Numata was the first one to expose a panoramic radiograph but he had placed the film lingually.

YEAR 1895 1896 1901 1904 1912 1913 1913 1913

EVENT Discovery of X-Ray First Dental Radiograph First Paper on Dangers Of XRadiation Introduction Of Bisecting Technique Invention Of Scatter Grid First Dental Text First Pre-wrapped Dental Films First X-Ray Tube

PIONEER /MANUFACTURER W.C.Roentgen O. Walkhoff W.H.Rollins W.A. Price Gustav Bucky H.R. Raper Eastman Kodak Co. W.D. Coolidge

1920
1923 1925

First Machine Made Film Packets

First Dental X-Ray Machine Introduction Of Bite-wing Technique

Eastman Kodak Co.

Victor X-Ray Corp.,Chicago H.R. Raper

1933 1947 1948

Concept of Rotational Panoramics Introduction of Long Cone Paralleling Technique Introduction Panoramic Radiography F.G. Fitzgerald

1955
1957 1978 1981 1987 2000

Introduction of D-Speed Film

First Variable KiloVoltage Machine Introduction of Dental Xeroradiography Introduction of E-Speed Film Introduction of Intraoral Digital Radiography Introduction of F-Speed Film General Electric

GENERATION OF X-RAYS

1.

2.

Central beam should pass through the area to be examined. The x-ray film should be placed in position so as to record the image with the least amount of image distortion

1.

PROJECTION RADIOGRAPHY Projection radiography remains one of the staples of radiology, although a little over 100 years old. It is by no means obsolete even in times of multimillion-dollar high-tech imaging equipment. The usual radiograph is a summation image of the exposed body part. The bulk of all diagnostic imaging studies is still done with this technology.

2. CONVENTIONAL TOMOGRPAHY In conventional tomography, only a single slice of the body is depicted while all others are blurred by motion. 3. FLUOROSCOPY Specifically used for diagnostic evaluation & interventional examinations of hollow organs.

RADIOGRAPHIC FILMS

Principal components; Emulsion Base.

EMULSION
Principle component of emulsion is Silver

halide grains & vehicle matrix. Silver halide grains are sensitive to light. Silver bromide is principally used, in newer films iodide is also added, which because of its larger grain size disrupts the regularity of crystals & increases its sensitivity to radiation. In addition, trace amounts of Sulphur compounds & gold is also added to increase the sensitivity. silver halide grains are suspended in a surrounding vehicle that is applied to both sides of the supporting base which keeps the crystals evenly dispersed. Thin layer of adhesive material is added to base to ensure good adhesion with the emulsion.

BASE

An additional layer of vehicle is added to the film emulsion as an overcoat; this barrier helps protect the film from physical damage.

Function of film base is to support the Emulsion. It must have proper degree of flexibility to allow easy handling of the film. It is 0.18mm thick & is made of polyester polyethylene terephthalate. Film base must withstand exposure to all the processing solutions without distortion. It is uniformly translucent & casts no pattern over resultant radiograph. Intra-oral films are double emulsion films which require less radiation. One corner of each film has a small embossed dot which is used for film orientation. Intraoral film packets either contain one or two films. when double film packs are used second film serves as duplicate record. Film is encases in a protective black paper wrapper to protect from light. This assembly is kept in a outer white paper or plastic wrapper which is resistant to moisture. Between the wrappers in the film packet is a thin lead foil backing with an embossed pattern. This lead foil shields film for backscatter & also reduces patient exposure.

GENERAL FUNCTIONS REDUCING AGENT

CHEMICAL METOL

SPECIAL FUNCTION
Quickly builds up gray tone in the image. Convert exposed silver halide crystals into black metallic silver Slowly builds up black tones & contrast. Swells & softens emulsion. efficacy of reducing agent. Prevents fog, by restraining Reducing agent from developing unexposed Silver halide Prevents rapid oxidation of developing agents For dissolving chemicals

HYDROQUINONE ACTIVATOR RESTRAINER SODIUM CARBONATE POTASSIUM BROMIDE

PRESERVATIVE SOLVENT

SODIUM SULFITE WATER

GENERAL FUNCTIONS
FIXING AGENT

CHEMICAL
AMMONIUM THIOSULPHATE

SPECIAL FUNCTION
Clears away the unexposed silver halide crystals. Neutralizes the developer. Thereby stops development. Shrinks & hardens the emulsion. Maintains chemical balance of fixer chemicals. For dissolving chemicals.

ACIDIFIER

ACETIC OR SULPHURIC ACID

HARDENER

ALUMINIUM CHLORIDE/ SULPHIDE SODIUM SULPHITE

PRESERATIVE

SOLVENT

WATER

Silver halide crystals are chemically sensitized by addition of Sulphur Compounds. These compounds create physical irregularities along with formation of sensitivity sites. Each crystal has many sensitivity sites, which begin the process of image formation by trapping the electrons generated when the emulsion is irradiated. Exposure to radiation chemically alters the photosensitive silver halide crystals to produce the latent image. Processing the exposed film in developer and fixer converts the latent image into the visible radiographic image.

Irradiation of silver halide crystal

Developer + Neutral Ag Atoms Solid Grains of Metallic Ag

Latent Image Site

Photon + Br Br + e

Fixer Dissolves Undeveloped, Underexposed AgBr Crystals

Formation of negatively charged sensitivity site

Ag + e Neutral Ag Atom

FINAL IMAGE

Must show images with optimum density, contrast, definition & detail. Images should have minimum distortion. Complete Mouth Radiographic Series(CMRS) must show all tooth-bearing areas including dentulous & edentulous regions. Periapical radiographs must show entire crown & roots of the teeth examined, as well as 2-3mm beyond apices. Bite wing radiographs must show open contacts, or interproximal tooth surfaces that are not overlapped.

A radiograph is said to be anatomically accurate when; The labial & lingual cemento-enamel junctions of anterior teeth superimpose. Buccal & lingual cusps of posterior teeth (especially molars) superimpose. Contacts of teeth are opened in at least one of the projections of a given area. Buccal portion of alveolar bone crest superimpose over lingual portion of alveolar bone crest. There is no superimposition of zygomatic process of maxilla over the roots of the maxillary teeth.

The principles of projection geometry describe the effect of focal spot size and position (relative to the object and the film) on image clarity, magnification, and distortion. Used to maximize image clarity, minimize distortion & localize objects. SHARPNESS- Measures how well a boundary between two areas of differing radio-density is revealed. SPATIAL RESOLUTION- measures how well a Radiograph is able to reveal small objects that are close together. Although X-Rays are produced in the same target, they originate from different points hence they reach on film at different points which causes blurring of edge of the image.

1.

Use as small an effective focal spot as practical.

Nominal focal spot size of 1.0mm or less A small angle has a greater wearing effect on the target but results in a smaller effective focal spot, decreased un sharpness, and increased image sharpness and resolution angle of the face of the target to the central x-ray beam is usually between 10 and 20.

2. Increase the distance between the focal spot and the object by using a long, open-ended cylinder
longer focal spot-to-object distance minimizes blurring by using photons whose paths are almost parallel.

3. Minimize the distance between the object and the

film

The increase in size of the image on the radiograph compared with the actual size of the object. Results from the relative distances of the focal spotto-film and object-to-film. Use of long open ended cylinder as an aiming device also reduces the magnification of images on the periapical view. Reduced in two ways

Increasing the focal spot-to-film distance and Decreasing the object-to-film distance minimizes image magnification

Result of unequal magnification of different parts of the same object. This is caused when not all the parts of an object are at the same focal spot-toobject distance. The Practitioner can prevent distortion errors by
Aligning the object and film parallel with each other. Orienting the central ray perpendicular to object & film.

A.K.A Right Angle or Long Cone Technique. Introduced by C. Edmund Kells in 1896 & Developed by Gordon M. Fitzgerald in 1947. He also introduced Long Cone Paralleling technique. Used by Franklin W. McCormack in practical dental radiography. So named because the object (tooth), receptor (film packet), and end of the beam indicating device (BID) are all kept on parallel planes. PRINCIPLE Image sharpness is primarily affected distance from the focal spot within the tube head and the film, object-film distance, motion, and the effective size of the focal spot of the x-ray tube.

Essential Conditions For Successful Radiograph

1.

2.

3.

The film packet should be flat. Film packet must be positioned parallel to the long axis of the teeth. Central ray of the xray beam must be kept perpendicular to the teeth and film.

It requires the use of Film Holders. Most commonly used are;

The Dentsply/Rinn XCP Instruments. The Snap-a-ray Film Holder. Hemostat film holder. Stabe Disposable Film Holder The Masel Precision Rectangular Instruments.

Collimating

Dentsply & Masel have an additional benefit in radiation reduction by use of Rectangular Collimation.

Dentsply/ Rinn Snap-A-Ray is particularly useful for;

Mandibular premolar & Molar projections. Maxillary & Mandibular third molar projections. Patients with Hypersensitive Gag Reflex. Children. Edentulous projections. Endodontic projections.

1. 2. 3.

4.

5.

6.

The film must be kept so that it covers the particular teeth to be examined. Vertical plane of the film must be parallel to the long axes of the teeth being radiographed. Horizontal plane of film must be parallel to horizontal planes of teeth. Vertical angulation of BID should be such that open ended flat surface of the BID is positioned parallel to the film packet. The horizontal positioning of BID should direct the XRays through embrasures or contacts between the teeth. The central X-Ray beam must be directed to the center of the film.

INCISORS Central Ray Entry Point-

CANINE C. R. Entry Point-

PREMOLARS
C. R. Entry PointPupil Of The Eye

MOLARS C.R . Entry Point-

Tip Of The Nose

Ala Of The Nose

Outer Canthus Of Eye

INCISORS
C.R . Entry PointCup Of The Chin

CANINE C.R . Entry Point-

PREMOLARS C.R . Entry PointPupil Of The Eye

MOLARS C.R . Entry Point-

Ala Of The Nose

Outer Canthus Of Eye

1. 2. 3. 4.

5.

6. 7.

White side of the film always faces the teeth. Film placement- anterior-vertical; posterior-horizontal Place the Dot in the Slot. When placing the film in the mouth, always lead with the apical end of the film & rotate the film holder. When positioning the film holder, always place the film away from the teeth & toward the middle of the oral cavity. Always center the film over the area to be exposed. Ask the patient to slowly close on the bite block & make certain that bite block is stabilized by teeth & not lips.

1. 2. 3.

It produces the image without Distortion. Simple & is easy to learn & use. Easy to standardize & can be accurately duplicated

1. Film placement may be difficult. 2. Film holding device may impinge on the tissues & may cause discomfort.

Set all exposure factors Remove intraoral objects & eyeglasses Use definite order to avoid errors Use bite block with Dot in the Slot. Explain all procedures & instruct patient on how to close & open. Always communicate with the patient. Always use the word Please. Do use praise. Instruct patients to Close Slowly Align the PID.

DOS

Bend or crimp a film packet. Use words such as Hurt. Make Comments such as Oops. Pick up a film packet if it drops. Allow the patient to dictate. Begin with the posterior exposures. Position films on top of a torus.

DONTS

Developed by Weston Price in 1904 PRINCIPLE:Central ray of the x-ray beam is aimed at right angles to an imaginary line which bisects the angle formed by the longitudinal axis of the tooth and the plane of the film packet. * Based on Cyzynskis Rule of Isometry Isometry. * It states that two triangles are equal e when they share one complete side & have two equal angles. * It is also defined as Equality of Measurement.

Head Position
For maxillary projections, Occlusal plane of teeth to be radiographed should be parallel to the floor & sagittal plane of Head should be perpendicular. For mandibular projections, Lip commisure- tragus line should be parallel to the floor. Film Placement The center of the film positioned behind the center of the region radiographed. Horizontal Angulation of BID As the BID moves around the arch , the X-Ray beam is directed perpendicular to the mean tangents of facial surfaces of the teeth under examination; the flat face of BID should be parallel to the horizontal plane of the film.

Vertical angulation of BID

Direct the central ray through the center of the field under examination, perpendicular to the line bisecting the angle formed by the planes of the long axes of the tooth & the plane of the film. Average vertical angles for Short BID (8 Inches) For Long BID(16)

FILM Molar

MAXILLAR Y RANGE +20 to +30

MANDIBULA R RANGE -5 to 0 -15 to -25 -20 to -30 -15 to -25 +10

FILM Molar Premolar Canine incisor Bitewing

MAXILLAR Y RANGE +25 +35 +45 +45

MANDIBUL AR RANGE 0 -5 -10 -15

Premolar +30 to +40 Canine Incisor Bitewing +45 to+55 +40 to +50

+6 to +8

Point Of Entry The X-Ray beam is directed through the center of the area to be radiographed. Objective of this film is to cover the film with the beam of radiation. If this is not done then Cone Cut or Partial Image will be seen.

FILM HOLDERS
1. 2. 3.

Dentsply/ Rinn Bisecting angle instruments Dentsply/ Rinn Stabe Disposable Periapical X-Ray Film Holders EEZEE- Grip Film Holder A.K.A Snap-A-Ray Film Holders

1.

2.
3. 4.

5.

6.

White side of the film always faces the teeth. Anterior films are always placed vertically. Posterior films are always placed vertically. Incisal or occlusal edge of the film must always extend approximately beyond the teeth. When positioning the film, always center the film over the area to be examined. If using the patients finger to stabilize the film, instruct the patient to gently push the film against the lingual surface of the teeth.

Can be used without the use of Film Holding Device. Can be used where anatomical considerations preclude the use of film holders e.g. shallow palate, bony growths, sensitive mandibular premolar area. When short BID is used exposure time is decreased causing decreased radiation dose.

1.

2.

3.

4.

5.

Bisecting angle rule applies well for plane surfaces but when applied to structures such as Teeth which also have Depth, resultant image can be Distorted. Structures that are farther away from the film appear more elongated than those closer to the film. Digital method of retaining the film in the mouth its most undesirable. Slippage of film may occur, resulting in inadequate exposure. Also digital pressure may cause unnecessary bending of the film.

DOS

DONTS

Set all exposure factors Remove intraoral objects & eyeglasses Use definite order to avoid errors. Place the film with identification dot towards occlusal edge. Instruct the patient on how to hold the film & remain still. Make certain that stabilizing finger or thumb is always positioned behind the film. Memorize recommended vertical angulations. Direct the central ray perpendicular to bisector. Align the opening of PID parallel to the imaginary bisector. Always use the word Please. Do use praise.

Bend or crimp a film packet. Use words such as Hurt. Make Comments such as Oops. Pick up a film packet if it drops. Allow the patient to dictate. Begin with the posterior exposures. Position films on top of a torus.

These are most frequently used to determine the location of a foreign object or an impacted tooth in the jaw. Two methods are used for localizing the object;
To examine two films projected at rigt angles to each other. 2. Tube shift technique. Taking projections at right angles to each other
1.

A.

Used to localize an object in or about the maxilla or mandible in three dimensions. In clinical practice the position of an object on each radiograph is noted relative to anatomic landmarks. The right angle or cross section technique is best in Mandible

B.

Tube shift technique This method is also known as buccal object rule or Clarks rule(1910) Rationale for this technique derives from the manner in which the relative positions of radiographic images of two separate objects change when projection angle at which the images are made is change.

SLOB (Same Lingual Opposite Buccal)

INTRAORAL PROJECTION & TECHNIQUE ERRORS ERROR Radiopaque artifacts on radiograph Blurred images on radiograph Apical ends of teeth are cut off CAUSE Leaving dental appliances in mouth &/or eyeglasses or jewelry on the patient. Movement of film, patient or tubehead during exposure a. Film placed too close to teeth in maxillary arch in paralleling technique b. Too flat a vertical angulation which caused elongation Faulty film placement Reversal of film Embossed dot being oriented in apical direction Film exposed twice to radiation use film cup The finger is placed in between film & the teeth

All of specific region not showing Herringbone effect or Ping pong Ball effect & light density Black dot in apical area Double images Phalangioma

Overlapping of teeth

1. Plane of the film is not parallel to lingual surfaces teeth 2. Incorrect horizontal angulation of BID Placing the film over tongue Bisecting Technique- to steep vertical angulation Paralleling technique1. Film not parallel to long axes of teeth 2. Long cone BID not properly positioned Bisecting Tech- Too flat vertical angulation Paralleling Tech1. Film not positioned parallel 2. Long cone not properly positioned

Tongue image Foreshortening

Elongation

Dimensional distortion of image

Inherent error in bisecting angle tech. produces elongation of palatal roots & foreshortening of buccal roots in same view
Film is bent as patient bites on film holder Cone of radiation not covering area of interest

Image distorted severly Cone cut

PROCESSING ERRORS
ERRORS
Low density (light) films

CAUSE
1. Solution temperature too low 2. Exhausted developer 3. Too fast processing 1. Overheated solution 2. Light Leaks 3. Too much replenishment 1. Dryer & developer temperature too low 2. Dryer air circulation inadequate 3. Too fast processing Contamination of fixer by developer solution

High Density (dark) films

Wet or Tacky Films

Film discolouration (Brown)

Film discolouration (greenish- Exhausted fixer solution or too fast processing yellow) Fogged Films 1. Incorrect safe lighting 2. Developer temperature too high 3. Improper storage of film 1. Under-replenishment 2. Dirty wash water 3. Film not hardened properly by chemicals

Streaking (uneven density)

Surfce marks

1. Foreign materials or irregularities on the surface of rollers used for automatic film processing 2. Rough handling of film before processing 1. Wash water not used or sirty wash water used 2. Contaminated fixer 1. 2. 3. 4. 5. 6. 7. 8. Chemicals contaminated or diluted Too high chemical temperature Excessively soft films Dirty rollers Racks not seated properly Dirty wash water Incorrect dryer temperature Hesitation in drive assembly, causing film to pause in transit 9. Improper feeding of the film 10. Bent film corners at leading edge.

Films chalky or dirty

Jams or failure of film to transport

FILM HANDLING ERRORS

ERROR
Black marks on film

CAUSE
1. Biting on the film e.g. pediatric occlusal film 2. Bending of the film 3. Saliva contamination 1. Static electricity 2. Removing film too rapidly form packet in air with dry humidity Careless handling

Black lighting or tree-like marks Torn emulsion & scratches

Dust & powder artifacts

White ball point pen marks FOGGED FILM 1. LIGHT FOG

Film contact with dust, grit or glove powder before processing

1. Light leaks 2. Turning overhead white light too soon

2. RADIATION FOG 3. CHEMICAL FOG

4. DETERIORATION OF FILM

Improper storage, insufficient protection 1. Developer temperature too high 2. Overdevelopement

1. Temperature of storage area too high 2. Too high humidity 3. Strong fumes(ammonia, paint)

EXPOSURE NUMBER

ARCH Maxillary Maxillary Mandibular Mandibular Maxillary Maxillary

SIDE Right Right Right Right Left Left

TEETH Premolars Molars Premolars Molars Premolars Molars

TEETH NUMBERS

1 2 3 4 5 6

4,5 1,2,3 28,29 30,31,32 12,13 14,15,16

7 8

Mandibular Mandibular

Left Left

Premolars Molars

20,21 17,18,19

EXPOSURE NUMBER
1 2

ARCH
Maxillary Maxillary Maxillary Maxillary Maxillary

SIDE
Right Right Right Left Left Left Left

TOOTH
Canine Lateral Incisor Central Incisor Central Incisor Lateral Incisor Canine Canine

TOOTH NUMBER
6 7 8 9 10 11 22

3 4

Maxillary Mandibular

Mandibular
Mandibular Mandibular Mandibular

Left
Left Right Right Right

Lateral Incisor
Central Incisor Central Incisor Lateral Incisor Canine

23
24 25 26 27

Mandibular

Also called as INTERPROXIMAL TECHNIQUE. Developed by Howard Riley Raper in 1925. PRINCIPLES OF BITEWING TECHNIQUE I. Film is placed in the mouth parallel to the crowns of the both upper & lower teeth. II. Film is stabilized when the patient bites on the bite wing tab or bite wing film holder. III.Central ray of the X-Ray beam is directed through the contacts of teeth, using vertical angulation of +10.

IV.X-Ray beam is accurately directed through the mandibular premolar contacts so that overlapping is minimal or absent in the maxillary premolar segment. V. To help prevent the cone cutting, C. R. is directed towards the center of the bitewing tab, which protrudes towards the buccal side. VI.Two posterior bitewing views, a premolar & molar, are prescribed for each patient but for children 12 years or younger only 1 view may suffice. VII.Mandibular canine is used as guideline as its placed more mesially than maxillary canine.

PREMOLAR PROJECTION

MOLAR PROJECTION

1)

2)

3)

4)

5)

For detecting inter-proximal caries in the early stages of development before it becomes clinically apparent. Because of the horizontal angulation used it may reveal secondary caries below restorations that may escape recognition in the peri-apical views. useful for evaluating the periodontal condition. As they provide good perspective of alveolar bone crest & changes in bone height. especially effective and useful for detecting calculus deposits in inter-proximal area, because X-Ray beam is directed through inter-proximal spaces. With vertical bitewing views, alveolar bone loss can be more efficiently recorded.

Occlusal radiography is defined as those intraoral radiographic techniques taken using a dental X-ray set where the film packet (5.7 x 7.6 cm) or a small intraoral cassette is placed in the occlusal plane.

USES: To precisely locate roots, supernumerary, unerupted & impacted teeth. II. To localize foreign bodies in the jaw & stones in the duct of sublingual & submandibular gland duct. III. To demonstrate & evaluate the integrity of anterior, medial & lateral outlines of maxillary sinus. IV. To obtain information about location, nature, extent & displacement of fractures of mandible & maxilla. V. To determine medial & lateral extent of disease e.g. cysts, osteomyelitis, malignancies etc. & to detect disease in palate or floor of mouth.
I.

MAXILLARY OCCLUSAL PROJECTIONS

Upper standard occlusal (standard occlusal)
Shows anterior part of maxilla & upper anterior teeth. CLINICAL INDICATIONS a. Periapical assessment of anterior teeth especially in children. b. Detecting presence of unerupted canines & supernumerary teeth. c. For determining buccal/palatal position of unerupted canines. d. Evaluation of size & extent of lesions. e. Assessment of fractures of anterior teeth & alveolar bone. Especially in children as film placement is straightforward.

Upper oblique occlusal (oblique occlusal)

shows

the posterior part of the maxilla and the upper posterior teeth on one side. CLINICAL INDICATIONS a. Periapical assessment of upper posterior teeth, especially in adult who are unable to tolerate periapical films. b. Assessment of condition of antral floor. c. Aid in determining position of roots displaced inadvertently into antrum during extraction. d. Assessment of fractures of teeth & associated alveolar bone including tuberosity

Vertex occlusal (vertex occlusal)

shows a plan view of the tooth-bearing portion of the maxilla from above CLINICAL INDICATIONS a. Assessment of bucco/ palatal position of unerupted canine. DISADVANTAGES i. lack of detail and contrast. ii. Primary X-Ray beam may be in direct line with the reproductive organs. iii.Relatively long exposure time needed in spite of use of intensifying screens. iv.Direct radiation to pituitary & lens of eye.

MANDIBULAR OCCLUSAL PROJECTIONS

Lower 90 occlusal (true occlusal)
Plane view of the toothbearing portion of the mandible and the floor of the mouth. CLINICAL INDICATIONS a. Detection of salivary calculi. b. Assessment of buccolingual position of unerupted teeth. c. Evaluation of buccolingual expansion of body of mandible. d. Assessment of displacement fractures of anterior mandible.

Lower 45 occlusal (standard occlusal)

Shows lower anterior teeth & anterior part of mandible

CLINICAL INDICATIONS a. Periapical assessment of lower anterior teeth, especially in children & adults who can not tolerate periapical films. b. Size & extent of lesions. c. Assessment of displacement fractures of anterior mandible in vertical plane.

Lower oblique occlusal (oblique occlusal)

This projection is designed to allow the image of the submandibular salivary gland, on the side of interest, to be projected on to the film CLINICAL INDICATONS a. Detection of radiopaque calculi in submandibular salivary duct. b. Assessment of buccolingual position of lower wisdom teeth. c. Extent & expansion of cysts, tumours or osteodystrophies in posterior part of body & angle of mandible

I. All radiographs must have acceptable image characteristics of detail,

definition, density & contrast.

Detail refers to the point-by-point delineation of minute elements of objects in the radiograph. It is responsible for maximizing the information. KVp & developing process. Definition refers to the distinctness & sharp demarcation of all the detail that make up the radiographic images. Distance factors, focal spot size, type of film & motion factors. Density is the general tendency of the film toward a lighter or darker overall appearance. Exposure time, mA, KVp, Developer solution freshness & room temperature. Contrast refers to difference in density between adjacent areas in the film. When it is too high, minute details in the bone are obliterated, too low, small carious lesions are difficult to read but bony changes are easily noticed. Processing solutions, KVp, Type of film, Absorption differences (subject contrast). Radiograph is free from film handling & processing errors & is not severely creases or stained.

II.

All crowns & roots, including apices, are fully depicted together with interproximal alveolar crests, tooth contact areas & surrounding apical bone regions.
All apices of all teeth, together with approximately of surrounding apical bone must be seen clearly at least once in a complete radiographic survey. Film covers all the interproximal, periradicular, &/or retromolar regions of the anatomical regions of interest. It includes distal of the canine on premolar radiograph & third molar region on molar radiographs. Radiograph should not exhibit cone cutting or partial images. Embossed dot should appear at the incisal or occlusal edge of radiograph.

III. Images of all teeth & other structures are shown in proper

relative size & contour with minimal distortion & without overlapping images, where anatomically possible.
Interproximal contacts of two posterior bitewing radiographs should not overlap. Images of teeth & other structures should not be distorted to the extent that radiographic interpretation is impossible.

Advantages of Digital Imaging over conventional radiography

Digital imaging eliminates hazards of film processing. Hazardous waste in form of chemicals & lead foil are eliminated. Images can be electronically transferred to other health care workers. Digital intraoral receptors require less number of radiation which results in lowering of patient absorbed radiation. Digital images are numeric & discrete in two ways 1. In terms of spatial distribution of picture elements (pixels) 2. In terms of different shades of gray of each of the pixel.

A digital image consists of a large collection of individual pixels organized in a matrix of rows and columns. At each pixel of an electronic detector, the absorption of X-Ray generates a small voltage. At each pixel, the voltage can fluctuate between maximum & minimum value & is therefore an analog signal. Production of digital image by analog to digital conversion (ADC). ADC consists of sampling & quantization Sampling means similar signals are grouped together. Quantization means every sampled signal is assigned a definite value. These values are stored in computer & represent the image.

DIGITAL DETECTORS are the most important component of this technique CHARGED COUPLE DEVICE First direct digital receptor adapted for intraoral radiography introduced in 1987. Uses a thin wafer of silicon as the basis of image recording.when exposed to radiation, covalent bonds between silicon atoms are broken producing electron-hole pairs. number of electron-hole pairs are directly proportional to amount of exposure that an area receives. Electrons are then attracted towards most positive potential in the device where they create charge packets. Charged pattern formed from individual pixel in the matrix represents latent image. Image is read by transferring pixel charges in a bucket brigade fashion Pixel size varies from 20-70 microns. Size is inversly proportional to cost.

1.

2. COMPLEMENTARY METAL OXIDE

SEMICONDUCTORS (CMOS)

These detectors are silicon-based semiconductors but are fundamentally different from CCDs in the way that pixel charges are read. Each pixel is isolated from its neighboring pixels and is directly connected to a transistor. The voltage in each transistor can be addressed separately, read by the frame grabber, and then stored and displayed as a digital gray value

3. PHOTOSTIMULABLE PHOSPHOR PLATES (PSP)

absorb and store energy from x rays and then release this energy as light (phosphorescence) when stimulated by other light of an appropriate wavelength. The photostimulable phosphor material used for radiographic imaging is "Europium-doped" barium fluorohalide. Barium in combination with iodine, chlorine or bromine forms a crystal lattice Addition of Europium causes imperfections in this crystal lattice. When exposed to a sufficiently energetic source of radiation, valence electrons in Europium can absorb energy and move into the conduction band These electrons migrate to nearby halogen vacancies (F-centers) in the fluorohalide lattice and may become trapped there in a metastable state While in this state, the number of trapped electrons is proportional to x-ray exposure and represents a latent image. When stimulated by red light of around 600nm, the barium fluorohalide releases trapped electrons to the conduction band Fiberoptics conduct light from the PSP plate to a photomultiplier

tube

Photomultiplier tube converts light into electrical energy. The variations in voltage output from the photomultiplier tube correspond to variations in stimulated light intensity from the latent image. The voltage signal is quantified by an analog-todigital converter and stored and displayed as a digital image

Technique for producing a single tomographic image of facial structures that includes maxilla & mandibular arches & their supporting structures. Curvi-Linear variant of Conventional tomography. Most useful for diagnostic problems requiring broad coverage. E.g. Trauma Localization of third molars Extensive disease Known or suspected large lesions Tooth development Developmental anomalies Retained teeth or Root tips

Described by Paatero & Numata Independently. Two adjacent disks rotate at the same speed in opposite directions as an XRay beam passes through their centers of rotation. In practice, the center of rotation is located off to the side, away from the objects being imaged. The rate of movement of the receptor behind the slit is regulated to be the same as that of the central ray sweeping through dental structures on the side of patient nearest the receptor. Structures on opposite side of the patient (near the x-ray tube) are distorted & appear out of focus because x-ray beam sweeps through them in the direction opposite that in which image receptor is moving. Structures near X-ray tube are so magnified that they appear as ghost images. So, only structures near the beam are captured as resultant image.

EQIPMENT PREPARATION

PATIENT PREPARATION

Load the cassette in the dark room. Cover the bite block with a disposable plastic cover-slip. Set the exposure factors(e.g. KV, mA etc.) Load the cassette in the unit & align all movable parts.

Explain. Place lead apron without thyroid collar. Remove all objects from head & neck area that may interfere with exposure.

PATIENT PREPARATION
Instruct

the patient to sit or stand as tall as possible. vertebral column must be as straight as possible. Instruct the patient to bite on the plastic bite block in the groove in end to end position. Position the mid-sagittal plane perpendicular to floor. Position the Frankfort plane parallel to the floor. Instruct the patient to position the tongue on the roof of the mouth & close the lips around the bite block. Instruct the patient to remain still while the machine is rotating during exposure.

PATIENT PREPARATION ERRORS

PATIENT POSITIONINING ERRORS

POSITIONING OF LIPS & TONGUE. POSITIONING OF FRANKFORT PLANE. POSITIONING OF TEETH WITH RESPECT TO FOCAL TROUGH POSITIONING OF MIDSAGITTAL PLANE. POSITIONING OF SPINE

GHOST IMAGES LEAD APRON ARTIFACT

ADVANTAGES

DISADVANTAGES

FIELD SIZE SIMPLICITY PATIENT COOPERATION MINIMAL EXPOSURE

IMAGE QUALITY FOCAL TROUGH LIMITATION DISTORTION EQUIPMENT COST

Convention al Film Based Tomograph y

Nuclear Medicine

Wide Angle Narrow Angle

Scanogr aphy

STEREO SCOPY

Comp uted Tomo graph y

Cone Beam Computed Tomograph y (CBCT)

Magnetic Resonance Imaging

CONVENTIONAL TOMOGRAPHY

Examination begins with the x-ray tube & film positioned on the opposite side of the fulcrum which is located within bodies plane of interest. As the exposure begins, the tube & the film move in opposite directions simultaneously through a mechanical linkage. With this synchronous movement of tube & film, the images of objects located within the focal plane (at the fulcrum) remain in fixed positions on the radiographic film throughout the length of the tube & film travel & are clearly imaged. On the other hand images of the objects outside of focal plane are continuously changing positions on the film; as a result, the images of these objects are blurred beyond recognition by motion unsharpness.

Types of Tomographic Movements

Uses tomographic angle more than 10. Allows visualization of fine structures that normally would be obscured by superimposition in conventional radiography. Using this technique layers as thin as 1mm can be imaged. Most useful when tissues with greater physical density such as bone are studied. Its an excellent technique for visualizing maxilla & mandible before placing dental implants. Disadvantage- reduces subject contrast.

Developed by J. MacKenzie Davidson introduced it in 1898. Understanding normal anatomic structures is easy with the use of stereoscopy. It has also been used to determine location of small intracranial calcifications & multiple foreign bodies in thick body sections. To evaluate the relationships of margins of bony fractures. This technique currently enjoys renewed interest for

evaluation of bony pockets in patients with periodontal disease. Morphology of TMJ. Assessment of relationship of mandibular canal to unerupted mandibular third molars. Assessment of bone shape when placement of dental implants is considered.

TECHNIQUE Requires the exposure of two films, one for each eye. Hence, this technique delivers double exposure to the patient.- Major Disadvantage. Between exposure patient is asked to maintain the position & the film is changed & tube I shifted from right eye to left eye. A tube shift equal to 10% of focal-film distance has been found to produce satisfactory results. After processing, films commonly are viewed on a stereoscope that uses either mirrors or prisms to coordinate the accommodation & convergence of viewers eyes so that brain can fuse the two images.

This uses a narrowly collimated, fan-shaped beam of radiation to scan an area of interest, sequentially projecting image data relative to this area onto a moving film. Much the same as in panoramic radiography. Scanograms demonstrate higher contrast with the perception of greater detail compared to images of standard radiography. This is because collimation of X-Ray beam reduces the amount of scatter. Soredex Scanora is a commercially available X-Ray unit capable of performing both linear & rotational scangraphy.

In rotational scanography the beam of radiation rotates about a fixed axis that is predetermined based on the area to be imaged. Imaging sequence used by this technique results in the production of two or four scanograms, each made with XRay tube in different position; thus multiple images are made & any two of which can be viewed as stereoscopic pairs. Rotational scanography has been found to be as effective as intraoral periapical films in assessment of periodontal disease & detection of periapical diseases.

This is currently the workhorse of Radiology. Invented by Godfrey Hounsfield in 1972. Applied primarily to visualize High Contrast anatomy like TMJ & dental implant diagnostics. Image produced by this technique is claimed to be 100 times more sensitive than conventional X-Ray systems. It also demonstrated difference between various soft tissues which were never seen before. Recent technical developments permit extremely fast volume scans that may serve to generate two-dimensional slices in all possible orientations as well as sophisticated three-dimensional reconstructions The radiation dose, however, remains high and continues to require a very strict indication for every intended CT. Contrast media are used in CT to visualize vessels and the vascularization of different organ systems. To better appreciate the inside of hollow viscera, iodine or barium contrast media are also given orally or instilled into the rectum.

WORKING PRINCIPLE

In computed tomography the x-ray tube continuously rotates around the cranio-caudal axis of the patient. A beam of radiation passes through the body and hits a ring or a moving ring segment of detectors. The incoming radiation is continuously registered, the signal is digitized and fed into a data matrix taking into account the varying beam angulations. The data matrix can then be transformed into an output image. In todays modern CT machines the tube rotation continues as the patient is fed through the ringlike CT gantry, thus generating not single slice scans but spiral volume scans of larger body segments. For each picture Element (pixel) the attenuation of the radiation is calculated and expressed as Hounsfield units (HU)

In its simplest form a CT scanner consists of a radiographic tube that emits a finely collimated, fan-shaped x-ray beam directed to a series of scintillation detectors or ionization chambers. Depending on the scanner's mechanical geometry, both the radiographic tube and detectors may rotate synchronously about the patient, or the detectors may form a continuous ring about the patient and the x-ray tube may move in a circle within the detector ring. These CT Scanners are known as Incremental Scanners because final image set consists of a series of contiguous or overlapping axial images. Newer scanners acquire the data in a spiral or helical fashion. With these scanners, while the gantry containing the x-ray tube and detectors revolves around the patient, the table on which the patient is lying continuously advances through the gantry. This results in acquisition of continuous spiral of data as X-Ray beam moves down the patient. Compared to incremental CT scanner, spiral scanners provide improved Multiplanar image reconstruction, reduced examination time (12 seconds versus 5 minutes) & a reduced radiation dose(up to 75%)

a.

The x-ray tube rotates continuously around the longitudinal axis of the patient. A rotating curved detector field opposite to the tube registers the attenuated fan beam after it has passed through the patient. Taking into account the tube position at each time point of measurement, the resulting attenuation values are fed into a data matrix and further computed to create an image. b. Modern volume CT scanner

CT Image is a digital image reconstructed by computer which mathematically manipulates transmission data obtained from multiple projections. 1080 projections constitute one scan. Data derived from these projections contain all the information necessary to construct a single image. The CT image is recorded & displayed as a matrix of individual blocks called Voxels(volume elements) Each square of the image matrix is called Pixel. Size of the pixel (about 0.1mm) is partly determined by the computer program. Length of the Voxel (about 1-20mm) is determined by the width of the X-Ray beam which in turn is controlled by pre-patient & postpatient collimators. Voxel length is analogous to tomographic layer in the film tomography. For image display each pixel is assigned a CT Number representing density. This number is proportional to the degree to which the material in the vowel has attenuated the X-Ray beam.

A. Data from single plane is image are acquired from multiple projections made during the course of a 360rotation around the patient. Dimension C(VOXEL) is controlled by prepatient & postpatient collimation. B. Single plane image is constructed from absorption characteristic s of the subject & displayed as differences in optical density(1000 to +1000) several planes can be imaged from multiple contiguous scans. C. Image consists of a matrix of individual pixels representing a face of a volume called Voxel. D. Cuboid Voxels can be created from original rectangular voxel by computer interpolation. E. This interpolation allows formation of Multiplanar & three dimensional images.

It represents the absorption characteristic or linear attenuation coefficient, of that particular volume of tissue in the patient. CT Numbers are also known as Hounsfield units may range from 1000 to +1000, each constituting a different level of optical density. This scale of densities is based on Air(-1000), water (0), Dense Bone(+1000).

Computer programs reformat the data available from axial CT scans into Three Dimensional images. This reformatting requires that each voxel, shaped as a rectangular parallel pipe or rectangular solid be dimensionally altered into multiple cuboidal voxels. This process, called as interpolation, creates sets of evenly spaced cuboidal voxels (cuberilles) that occupy the same volume as original. CT numbers of cuberilles represent the average of original vowel CT numbers surrounding each of the new voxel. Creation of these new voxels allows image to be reconstructed in any plane without loss of resolution.

In construction of this 3-D image only cuberilles representing the surface of the object scanned are projected on to the viewing monitor. This surface appears as if illuminated by a light source located behind the viewer. In this way, the visible surface of each pixel is assigned a gray level value, depending on its distance from & orientation to the light source. Thus pixels that face the light source appear brighter than those that are farther away. This effect of shading is analogous to an artists 3-D rendering of an object within 2-D medium. Once constructed these 3-D images can be manipulated in any plane & also external surface of the image can be removed to view deeper anatomy.

One of the first applications of 3D CT was the study of patients with suspected inter-vertebral disk herniation and spinal stenosis Since that time it has been applied to craniofacial reconstructive surgery& has been used for
Treatment of congnital & acquired deformities For evaluation of intracranial tumours Benign & malignant lesions of maxillofacial complex Cervical spine injuries Pelvic fractures Deformities of hand & feet Trial surgeries & construction of surgical stents for guiding dental implant placement Creation of accurate implant prostheses

Uses a Round or a rectangular cone shaped X-Ray beam centered on a 2-D X-Ray sensor to scan a series of 360 exposures or projections, one for each degree of rotation. This provides raw digital data for reconstruction of exposed volume by computer algorithm. Depending on the equipment scan time ranges from 17 seconds to little above 1 minute. Multiplanar reformatting of primary reconstruction allows for both 3-D & 2-D images of any selected plane to be made. Visual resolving power of these systems is four times more than that of Computed Tomography. The radiation dose delivered to a patient is 3%-20% less tha conventional CT scans. Systems available

3D Accuitomo (J. Morita, Kyoto, Japan) The NewTom Plus (Quantitative radiology, s.r.l., Verona,Italy)

Magnetic resonance imaging (MRI) uses nonionizing radiation from the radiofrequency (RF) band of the electromagnetic spectrum. To produce an image , the patient is placed in a large magnet , which induces a strong magnetic field. This causes the nuclei of many atoms in the body, including Hydrogen, to align themselves with the magnetic ield. After application of a radiofrequency signal, energy released from the body is detected & used for construction of MR image on the computer. High contrast sensitivity of MRI to tissue differences & the absence of radiation exposure have replaced CT with MRI for imaging soft tissues.

Periodontally compromised patient requires special consideration for remaining teeth & potential implant sites & remaining alveolar bone Radiographic technique of choice is the long cone paralleling technique. To decrease the dosage as much as possible , fast (E or F speed) films must be used with narrowly collimated beams. Prichards criteria for determining adequate angulation 1. Radiograph should show tips of molar cusps with little or none of the occlusal surface showing. 2. Enamel caps & pulp chambers should be distinct. 3. Interproximal spaces should be open. 4. Proximal contacts should not overlap unless teeth are out of line anatomically. when the anatomic conditions make it impossible to place intraoral films parallel to the vertical axis of the alveolar process, a better estimate of the bone height can be made in panoramic radiographs.

Conventional radiographs are very specific but lack sensitivity. Variations in image quality resulting from variables inherent to conventional radiography can be reduced with digital radiography. This allows the use of computerized images which can be stores, manipulated & corrected for underexposures & overexposures. It also causes reduction in radiation to patient. Subtraction radiography has been introduced as a technique in periodontal diagnosis. It relies on conversion of series of radiographs into digital images. These images are then serially superimposed & changes in the density & volume of bone are assessed This technique facilitates both qualitative & quantitative visualization of even minor density changes in bone by removing unchanged anatomic structures from the image. Recently newer subtraction method called, Diagnostic subtraction radiography(DSR) have been introduced. It combines the use of a position device during film exposure with specialized software designed for digital image subtraction using conventional personal computers.

COMPUTER ASSISTED DENSITOMETRIC IMAGE ANALYSIS SYSTEM (CADIA) In this system a video camera measures the light transmitted through a radiograph & the signals from the camera are converted into Gray Scale images. Camera is interfaced with an image processor & a computer that allow the storage & mathematic manipulation of the images. Compared to DSR, CADIA has shown higher sensitivity& high degree of reproducibility & accuracy.

When implants are to be inserted between teeth, between a tooth and the mental foramen, or between a tooth and the anterior border of the maxillary sinus, supplementary intraoral radiographs should always be obtained. They should be taken with a direction of the X-ray beam perpendicular to the tangent of the alveolar arch. Inaccurate horizontal angulations can easily make distances of interest appear too small or less frequently too large.

Tomography is used to determine Bone Width but trabeculae of the bone can only be assessed by intraoral radiographs. Only cross-sectional tomography can provide a good enough depiction of the mandibular canal and provide a basis for the necessary measurements. For the best estimate of height and width of the implant site, cross-sectional tomography should be carried out. A correct position of the tomographic layer implies that it is perpendicular to the tangent of the jaw curvature and to a horizontal reference plane. To obtain correct positions of the tomographic layer relative to one of these horizontal reference planes the patient's head may have to be slightly tilted forwards or backwards

Digital systems have also been tried because they provide less radiation dosage as well as show structures with small mass density. Among the available digital systems Image plate system have shown the widest dynamic range. Images can also be altered with these systems, so as to better visualize the marginal bone & implant components. Edge enhancement feature available with digital techniques is of a specific value to view the margins between implant & surrounding bone. Subtraction radiography with pseudo-colouring can also be used to demonstrate changes between radiographs that are not readily visualized.

Many of the early pioneers suffered from the adverse effects of radiation. Protection is always better than cure PATIENT PROTECTION These techniques are used before, during & after exposure. Before exposure Before exposure protection depends mainly on proper prescribing of dental radiographs. Every patients dental condition is different so every patient should be evaluated for radiographs on an individual basis. ADA along with FDA has given some specific guidelines for prescription of dental radiographs, these guidelines should always be followed. Another important step is use of proper equipment. It includes use of

1. 2. 3.

Added filtration- in forms of Aluminium disk Collimators- used to restrict the size & shape of the X-Ray beam. BID- rectangular type is most effective in reducing patient exposure.

During exposure Thyroid collars Lead aprons Fast films Film holding devices Exposure factor selection Proper technique Avoid all retakes After exposure Proper film handling Proper film processing

OPERATOR PROTECTION All protection guidelines are based on a primary rule that, the dental radiographer must avoid the primary beam. Distance recommendations Dental radiographer must stand at least 6 feet away from X-Ray tubehead. When maintaining a distance is not possible a protective barrier must be used. Position recommendations To avoid primary beam, dental radiographer must stand perpendicular to primary beam, or at a 90 to 135 angle. Dental radiographer must never hold the film in mouth. Dental radiographer must never hold the X-Ray tubehead during exposure.

Shielding recommendations Protective barriers that absorb the radiation must be installed in the dental offices so as to protect the operator from primary as well as scattered radiation. Whenever possible radiographer must stand behind these barriers. Radiation monitoring Radiation monitoring includes monitoring of machine as well as personnel. X-Ray machines must be monitored for leakage radiation Amount of X-Radiation reaching to a radiographers body must be monitored through the use of film badge

Radiation Exposure Guidelines Radiation protection standards dictate the maximum dose of radiation an individual can receive. This Maximum Permissible Dose (MPD) is the dose of radiation that the body can endure with little or no injury. Current MPD guidelines
Occupationally exposed persons- 5 rems/year (0.05sv/yr) Non-occupationally exposed- 0.1 rem/yr Occupationally exposed pregnant woman- 0.1 rem/yr Occupationally exposed persons must not exceed an accumulated lifetime radiation dose. It is referred to as maximum accumulated dose (MAD) MAD= (N-18) 5 rems/yr N- persons age in years. ALARA

It stands for as low as reasonably achievable

Oral Radiology- Principles & Interpretation- White & Pharoah Dental Radiography- Principles & Techniques- Haring & Howerton Principles of Dental Imaging- Langland, Langlais, Preece Essentials of Dental Radiography & Radiology- Eric Whaites Getting Started In Clinical Radiology- Eastman, Wald, Crossin Radiation Protection Panoramic Radiology- Seminars on Maxiloofacial Imaging & Interpretation- Allan G. Farman Clinical Periodontology- Carranza Clinical Periodontology & Implant Dentistry- Jan Lindhe World Wide Web