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Tony Ngan-Fat To*

BDS, PDipGDS

DENTAL PRACTICE

Hong Kong Dent J 2009;6:46-8

Alfred Chee-Ching Tsang

DDS, FFDRCS, FHKAM (Dental Surgery), FCDSHK

Localization of impacted maxillary anterior


tooth with tangential radiograph

* Department of Health, Hong Kong

ABSTRACT
An occlusal film placed parallel to the midsagittal plane of the head can be used to locate
the bucco-palatal position of the supernumerary teeth. The same principle can also be
applied with the central ray directed tangentially to the impacted canine for location of
bucco-palatal position. This approach requires minor modification of the radiographic
film-holding device and can be employed in all dental office settings. Two cases regarding
this technique were also presented.
Key words: Radiography, dental; Tooth, supernumerary

Introduction
The position of the supernumerary teeth in relation to the root of the maxillary anterior
teeth is important for determining the surgical approach used for their removal. The
prevalence of supernumerary teeth is 1 to 3% 1. Also, determining the bucco-palatal
position of an unerupted and impacted canine (which has a prevalence rate of 2.56% 2) is
essential to enable the orthodontist to formulate the treatment plan.

Principle of parallax

Correspondence to:
Dr. Tony Ngan-Fat To
Kennedy Town Community Complex
Dental Clinic, 10/F, Kennedy Town
Community Complex, 12 Rock Hill Street,
Kennedy Town, Hong Kong
Tel
: (852) 3583 3472
Fax
: (852) 3583 3430
e-mail : tonynfto@netvigator.com

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Hong Kong Dental Association

Traditionally, two radiographs of the same region with different angulations are used to
localize the position of the unerupted supernumerary teeth or canine. The difference in
angulations can be in the horizontal or vertical direction. Clark 3 described a technique
where the position of the buried tooth is compared in three periapical radiographs, one
central, one mesial, and one distal to the buried tooth. This approach is commonly referred
as Clarks rule and applies the principle of parallax to delineate the spatial relationships of an
object. The parallax technique utilizes the apparent displacement of the image of an object
relative to the image of a reference object caused by changing the angulation of the X-ray
beam. The image of an object that is more distant from the X-ray tube (palatally positioned)
moves in the same direction as the tube, whereas the image of an object closer to the X-ray
tube (buccally positioned) moves in the opposite direction to the tube. The acronym SLOB
(Same Lingual, Opposite Buccal) can help clinicians to remember the principle of tube shift.
Keur 4 used two occlusal films rather than two periapical films for a horizontal tube shift.
As occlusal films cover a larger area, the tube can be moved more, resulting in a more distinct
shift of images. A larger film may also have a better chance of showing the entire tooth.

Localization with tangential radiograph

With the availability of orthopantomography (OPG),


Keur 4 introduced another commonly quoted method using
panoramic and occlusal radiographs for vertical tube shift. In
radiating the maxillary anterior region with OPG, the source
of the radiograph is positioned behind the patients head at
an angle of -7 degrees to the occlusal plane and the film is in
front of the head. When compared with an anterior occlusal
radiograph, which is taken at an angle of +60 to 65 degrees to
the occlusal plane, the OPG can be interpreted as the central
beam with a vertical angle of +7 degrees to the occlusal plane.
Even though the OPG and the occlusal radiograph lie in two
different planes, the principle of parallax can still apply. Also,
because of a greater difference in the vertical angulations,
there will be a larger shift of the image, a feature that will
facilitate interpretation. If the impacted tooth moves apically
relative to the apices of the anterior teeth in the occlusal
radiograph (+60 degrees) in comparison with the OPG (+7
degrees), the impacted tooth is lingual (palatal) to the root
of the reference tooth. Conversely, if the impacted tooth
moves incisally relative to the reference point in the occlusal
radiograph when compared with the OPG, the impacted
tooth is situated on the buccal aspect of the reference teeth.
According to Jacobs 5, both the positions of the crown and of
the root apex should be checked in order to get a full picture
of the position of the impacted tooth.
With the advent of computed tomography (CT), the
spatial relationship of the impacted teeth in relation to the
other anatomical structures can be shown clearly in the 3dimensional reconstruction images of the CT scan or cone
beam CT. However, such equipment is not readily available
in a general dental office.

Tangential radiograph
In most clinical situations, the position of the impacted tooth
can be ascertained. In doubtful cases, however, we have
employed the following technique to confirm the exact
location of the buried tooth. The position of the impacted
tooth is located by lateral radiographic projection using an
occlusal film placed parallel to the midsagittal plane of the
head. The occlusal film is mounted on a film holder, which
has been modified to allow fitting to the cone head of the
radiographic machine (Figure 1a). This setup will ensure that
the central beam is perpendicular to the occlusal film to
minimize distortion. Since the patient is not required to hold

(a)

(b)

Figure 1
(a) Film holder mounted on the X-ray tube, and (b) the
direction of the X-ray beam is at a tangent to the unerupted tooth

the film, movement leading to film blurring can be avoided


(Figure 1b). The intraoral X-ray machine is set at 7 mA, 60 kV,
with an exposure time of 0.318 second when using type 1 film.
The resultant radiograph is developed in the usual manner.
The position of the buried tooth will be well demonstrated
in the film. When a supernumerary tooth is situated on the
palatal side, its image will be overlapped by the adjacent
anterior teeth. However, its position can be confirmed by
its absence on the buccal side. The same technique can be
utilized to locate the position of an unerupted canine, with
the central ray directed tangentially to the canine eminence.

Case reports
In Case 1, the impacted left maxillary canine was shown in
OPG (Figure 2a). A radiograph was then taken tangentially to
the impacted canine (Figure 2b) showing that it was located
buccally. In Case 2, a patient presented with an impacted
right maxillary canine and an unerupted supernumerary
tooth at the apex of the left central incisor, as shown in OPG
(Figure 3). The position of the canine and supernumerary
tooth is clearly shown in the tangential radiographs (Figure
4).

Hong Kong Dent J Vol 6 No 1 June 2009

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To and Tsang

(a)

Figure 3
Orthopantomography showing an impacted right upper
canine (black arrow) and supernumerary tooth (white arrow) in Case 2

(b)

(a)

(b)

Figure 2
(a) Orthopantomography
showing an impacted left upper
canine; and (b) tangential film showing
that the impacted canine was located
buccally (arrows) in Case 1

Discussion
Since 1910 when Clark 3 introduced the method of
employing three radiographs at different horizontal angles
for the localization of impacted maxillary anterior teeth, the
parallax method has remained the radiographic technique
of choice. Keur 4 was credited for advocating the use of
occlusal radiographs instead of periapical radiographs. He
also introduced the OPG and occlusal radiograph in the
vertical tube shift technique. However, in our experience,
there are situations when the exact location of the
impacted tooth can still be difficult to ascertain with these
techniques. In the OPG/occlusal radiograph technique,
the plane of the occlusal film is almost perpendicular
to the plane of the OPG film. This angulation difference
may nullify the change in angulations of the radiographic
source. Furthermore, the projection of the structures in
an arched maxilla onto a flat plane radiograph will cause

Figure 4
Tangential films showing that (a) the supernumerary
tooth (white arrow) and (b) the impacted right upper canine (white
arrow) were located buccally in Case 2

magnification differences in the OPG and the occlusal


radiographs. This will render interpretation of the shifting
of images more difficult. The tangential radiograph can
give valuable information for localization as it offers direct
visualization in the parasagittal plane, which demonstrates
the buccal and palatal relationship of the structures. It is
particularly useful in communication with the patient as
it can give the actual spatial relationship of the impacted
tooth and the adjacent teeth. With minimal modification
of any type of film-holding device, such as trimming away
part of the plastic ring to allow fitting into the cone head of
the radiographic machine, the tangential radiograph can
be taken using any intraoral radiographic machine.

References
1.
2.
3.

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Primosch RE. Anterior supernumerary teethassessment and


surgical intervention in children. Pediatr Dent 1981;3:20415.
McKay C. The unerupted maxillary canine. An assessment of the
role of surgery in 2,500 treated cases. Br Dent J 1978;145:207-10.
Clark CA. A method of ascertaining the relative position of

Hong Kong Dent J Vol 6 No 1 June 2009

4.
5.

unerupted teeth by means of film radiographs. Proc R Soc Med


1910;3(Odontol Sect):87-90.
Keur JJ. Radiographic localization techniques. Aust Dent J
1986;31:86-90.
Jacobs SG. Localisation of the unerupted maxillary canine. Aust
Orthod J 1986;9:311-6.