Dental X-Ray Films

X-ray films are used as an image reception system in dental radiology.

Image refers to picture or reflection of an object.
Receptor means anything that responds to a stimulus.
It is useful for recording the image of a patient's teeth and surrounding structures. The X-ray
films are very important in the diagnosis of pathology.
Radiographic film consists of transparent, blue tint base coated on both sides with sensitive
emulsion.
Classifications of dental X-ray film
According to use
o Intraoral films: these films are used for taking intraoral radiograph. It is non-
screen film that consists of an emulsion spread on both sides of relatively rigid
but flexible film base. They are of following types:
• Periapical films: these are used to take periapical radiographs. These films
are available in different size as follow:
 Size 0 for children
 Size 1 for anterior teeth adults
 Size 2 for posterior teeth adults
It records the outline, position, and dimension of teeth.
• Occlusal films: these films are larger than periapical films and they are
mainly used to take occlusal projection for detection of lesions. They
record image of an entire arch on one film.
• Bitewing films: these films are used for detection of proximal caries and
alveolar bone loss. These film records an image of crowns and
interproximal regions of maxillary and mandibular teeth.
o Extraoral films: thse films are used for taking al extraoral radiographs. These are
used in combination with intensifying screen.
o Duplicating films: these are the films which are used only when duplication of
radiograph is required. These are single emulsion films.
According to speed of film
Slow speed film: this type of film contains small size of grains of silver halids. These
film gives better definition, but it requires more exposure time as these films are usually
coated with emulsion on one side only. They are denoted by A, B, and C speed.
Fast speed films: these films have larger grain, and coating of emulsion is present on
both sides of the film, so that these films require less exposure time. These are denoted
by D (ultra speed), E ( eka speed), and F ( ultra eka speed) speed.
Hyperspeed G: this is 800 speed film that reduces the patient exposure.
According to packing
 Single film packet: the film packet contains only single film.
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  Double film packet: the packet contains 2 films. They are used when duplicated
radiograph is desired or when the dentist wants a fully or under processed radiograph of
the same area. These types of films require slightly more exposure as compered to single
packet films.
According to emulsion
❖ Single emulsion film: in these type of film, emulsion is coated on only one side of the
film. In this type, film is viewed from emulsion side.
❖ Double emulsion: in this emulsion is coated on both sides. Film can be viewed from
either side. These type of film requires less exposure as compared to single emulsion
film.
According to sensitivity
Direct action or non-screen film (wrapped or packet film): This type of film is sensitive
to X-ray photons.
Indirect action or screen film: It is used in combination with intensifying screen in a
cassette. It is sensitive primarily to light photons, which are emitted by the adjacent
intensifying screen on exposure to X-rays to X-rays. Advantage of using these type of
film is that exposure to the patient is minimized . It is minimized. It is mainly of two
types:
✓ Blue light sensitive: these films contain calcium tungstate in the screen.
✓ Green light sensitive: these films contain rare earth elements.
Intraoral films
Periapical films
Uses: it is used for taking periapical radiograph.
Availability: film packets are available in 25, 100, 150, film per container, They are packed in
convenient plastic trays or a card-board boxes that can be recycled.
Size: These films are available in different size as follow:
• Size 0: it is the smallest film used for children. It has a dimension of 22*35 mm or
0.814*1.296 inches.
• Size 1: it is used for anterior region. It has a dimension of 24*40 mm or 0.888*1.481
inches.
• Size 2: it is also called standard film and it is used for anterior and posterior projection
in adults. It has a dimension of 31*41 mm or 1.148*1.518 inches.
Bitewing films
Structure: these films are with bite tabs/wings attached to the film packet or it is constructed
from periapical films and bitewing loops. It shows the crown of both arches and their
interproximal alveolar bone crest in the same radiograph.
• Size 0: used to posterior teeth in children
• Size 1: examine posterior teeth in mixed dentition
• Size 2: examine posterior teeth in adult

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 • Size 3: it is narrower and longer and used only in case of bitewing radiograph. Size of
this film is 27*54 mm or 1.062*2.125 inches.
Occlusal films
It is usually positioned in the occlusal plane and patient occludes on it.
Size: it is usually 57*76 mm or 2.111* 2.814 inches.
Content of film packet
1. An outer plastic wrapper: it is made of non-absorbent paper or plastic or soft vinyl which
is waterproof and is sealed to prevent the ingress of saliva and light. It has 2 sides
A. Tube side: the side of packet that face towards the X-ray beam has either a
pebbled or a smooth surface and is usually white.
B. Labelled side: the reverse side is usually of 2 colour. Colour codes are used to
distinguish between 1 film and 2 films packet and film speed.
Information present on labelled side: on this side usually name of the manufacture,
number of films enclosed, a circle or dot corresponding with rised identification dot
on the film, statement regarding placement of the film and speed of the film are
mentioned.
The corners of the plastic packets are round to avoid discomfort to patient.
2. A sheet of lead foil: it is placed behind the film to prevent amount of residual radiation
that has pass through the film to continue into the patient's tissues. It is also used to
prevent scattered radiation from reaching the film which is formed due to interaction of
X-ray photons with the soft tissues beyond the film which cause film fog leading
degradation of the film. It is also contributed to rigidity to the packet.
3. A protective black paper: It is used for protect the film from light, damage by fingers,
while being unwrapped and contamination from saliva which may leak into the film
pocket.
4. The film: It has rounded corners and an embossed raised dot for orientation. The side of
film with the dote is placed towards the X-ray beam. Embossed dot should be placed on
the incisal/occlusal margin of the tooth to prevent any supperimpostion of dot on vital
structures. When the film mounted the convexity of this embossed dot should face
towards operator as if he is facing the patient.
Ideal requirements for X-ray
✓ It should require smallest possible quantity of X-ray to produce blackening.
✓ Change in the intensity of X-ray must produce clearly distinguishable densities
on finished film.
✓ Greatest possible effect must be produced in shortest possible time.

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Composition of X-ray film
It is composed of radiation sensitive or photographically active emulsion usually coated on
both sides of a transparent sheet of plastic called base
Base
It is the transparent supporting material upon which the emulsion is coated.
Composition: It is made of clear transparent cellulose triacetate or thin polyester plastic
(polyethylene terephthalate), which acts as a support for the emulsion but does not contribute
to the final image.
Polyester base is used because it is more resistant to warping with age, and it is stronger and
thinner than triacetate. This type of film base is called safety film base non-inflammable.
Thickness of base is 0.007 inch or 0.2 mm.
Requirement of base:
Bluish tint: the base should have bluish tint for ease in case of viewing, and it also
prevents eyestrain.
Flexible and allow easy handling of the film.
Support: it should serve as support for the very fragile emulsion layers.
Dimensional stability: the base should maintain its size and shape during use and
processing which called dimensional stability.
Inert: the base should be inert so that sensitometric property of emulsion is not affected.
Translucent: it should be translucent so that it does not cause any pattern image in the
resultant radiograph.
Adhesive
Between the emulsion and the base, there is thin coating of the material called adhesive layer
to ensure uniform adhesion of the emulsion to the base.
Emulsion
It is sensitive to X-rays, static electricity and visible light, and it records the radiographic
image. The sensitivity depends upon the size and thickness of the emulsion.

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It is present on both sides of the film so called double coated film which reduce exposure by
half. It is composed of two main ingredients :
• Silver Halide Crystals: Silver Halide is the light sensitive material in the emulsion. The
“halide” in silver halide is mainly bromide. Diameter of silver grains is about 0.7 to 0.75
mm. Silver halide crystals are produced by dissolving metallic silver in nitric acid to
form silver nitrate. The light sensitive silver bromide crystals are formed by mixing the
silver nitrate with potassium bromide. Silver bromide is usually tiny flat triangular
crystals which should be uniformly distributed throughout the gelatin to become equally
sensitive.
• Gelatin: Gelatin keeps the silver halide grains evenly dispersed and prevents clumping
of the grains. You can think of the emulsion as being kind of like a Jell-o mold…gelatin
with particles of fruit cocktail floating in it. But wait. There are many types of Jell-o
mold. Some like bigger chinks of fruit . Some like carrots instead of fruit. Thickness
10 um.
Crystals of silver bromide consist of array of silver and bromine in cubical structure.
Impurities: the crystals include extremely small impurities which disturb the peripheral energy
level. One of the most common types is sulphur, which causes small silver sulphide defect
through the silver bromide crystal lattice. This defect acts as trapping center which may acquire
X-ray photons.
Gelatin matrix: silver halide crystals are suspended uniformly in matrix present on both sides
of emulsion. It is made of cattle bone and is porous to allow the processing chemicals to
penetrate it and gain access to silver halide crystals. It is transparent to transmit the light.
Gelatin super coat: it acts as a during processing. It also protects emulsion from pressure of
roller while automatic processing. It is transparent so that light can pass through it.
Speed or sensitivity of X- ray:
It is the amount of radiation required to produce the radiograph of adequate density.
1. Slow film: intraoral films that require more exposure to produce ideal radiograph are
called slow speed film. Group A,B, and C.
2. Fast film: intraoral films may vary in speed. An intraoral film that requires very little
exposure to X-radiation to produce radiograph is called fast film or sensitive film. Group
D, and E. disadvantages of fast film is that it can affect the contrast of film which gets
reduced as film E is most commonly used.
Factors affecting film speed:
 Size of the crystal: film speed is affected by the size of the crystals. If the size of crystal
is more, then speed of the film will more and vice versa.
 Shape of grains: the tubular shape grains give more surface area and it will reqire less
exposure and speed of the film will be more.
 Thickness of emulsion: if thickness of emulsion is more Thickness of emulsion: if
thickness of emulsion is more, then speed of the emulsion will be more.

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  Radiosensitive dyes: if radiosensitive dyes are incorporated in the emulsion that
increases the speed of the film.
T Grain film: group E speed film called Eka speed film(E+) it uses flat or tubule grain or T
grains in the emulsion. It gives greater surface, it uses flat or tubular.
Film holding device
It is the device that is used to position an intraoral film in the mouth and maintain the film in
position during exposure. It is used in preapical techniques as parallel line angle and bisecting
angle techniques.
Types of film holders
Most commonly used film holding devices are:
 tongue depressor
 haemostat with bit-block
 the stape disposable styrofoam bite-block with backing plate and slot for film retention
 the snap-A ray intraoral film holder
 extension cone paralleling device
 precision rectangular collimating instrument
Ideal requirements of film holder
❖ it should be adaptable in most situation
❖ it should be disposable or could be autoclave
❖ it should be held by patient's teeth
❖ it should be able to place the film at any position in the oral cavity
❖ it should hold the film firmly without slipping
❖ it should be not bulky
❖ it should allow maximum closure of patient's mouth to deepen the floor of mouth
❖ it should need little biting force
❖ it should be able to be used with rubber dam and clamp in patents mouth.
❖ It should assist in X-ray beam positioning
Advantages of film holder
✓ It allows the placement of the film parallel to the tooth.
✓ Film is properly retained in the oral cavity so properly exposed.
✓ Reduction of exposure to patient .
✓ Cone cut is avoided due to parallel placement of the film.
Disadvantages of the film holder
 Placement of the film beyond the apical region.
 Abnormal anatomical condition like tori.
 It is not possible for operator to check the position of the film just before the exposure.
 There may be some sort of discomfort to the patient.
Basic components of film holder

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 A mechanism for holding the film packet parallel to the teeth that also prevent bending
of the packet.
A bite block.
X-ray beam device
Extraoral films
Types
Non-screen film: These are used without intensifying screen. These films are much
slower and require longer exposure time. Details of the image are more.
Screen film: these are kept in cassette between the intensifying screens. They are placed
in rigid manner, so t, so that emulsion of film and film and fluorescent layer of screen
touch each other. It requires fewer X-ray to expose the film is much more efficient in
absorbing X-ray photons. efficient in absorbing X-ray photons.
Uses
✓ It is used as image detector whenever it is possible, particularly when fine details are
not required.
✓ The main use includes lateral oblique view, all skull radiographs, dental panoramic
radiograph, and all routine medical radiographs.
✓ It is also used in vertex occlusal radiograph.
Sizes
Lateral obliue film: 5*7 inches
Panoramic film: 6*12 or 5*12 inches
Cephalometric film: 8*10 inches
Skull radiography: 10*12 or 6*12 inches
Film construction
Emulsion: The silver halide emulsion is designed sensitive primarily to light rather than X-
ray. Different emulsion according to sensitivity of different colours:
• Blue light standard silver halide emulsion is sensitive to blue light.
• Ultraviolet light: Modified silver halide emulsion with ultraviolet sensitizer sensitive to
ultraviolet light.
• Green light: Orthochromatic emulsion sensitive to green light. These are two to more
times faster and provide sufficient clarity of most diagnostic tasks. These are most
commonly used extraoralfilms in case of panoramic and cephalomatic radiography.
• Red light: Panchromatic emulsions sensitive to red light.
They do not have embossed dot to indicate the surface facing the X-ray. They are used in film
holder or cassettes that have letter R or L made of lead on exposure side of the cassettes.
High contrast medium speed films are suitable for panoramic and skull radiography. But films
with less contrast and wider latitude are used in case of cephalomatric soft tissue radiography.
The film are similar in structures as intraoral films.
Film storage

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All radiographic film deteriorate with time. Storage condition can effect deterioration rate.
The storage of film should be:
1. In cool place temperature between 50 -700 F.
2. Humidity should be 30-50%.
3. Away from any sources of ionizing radiation.
4. Away from chemical fumes including Hg and Hg compounds.
5. The film should not be placed one over other to avoid pressure effect.
6. The film should be stored in light proof area.
7. The oldest film should be used 1st.
8. Handling of the film should be done carefully to avoid scratches.
Intensifying screen
Intensifying screen consists of fluorescent phosphors, suspended in an inert transparent binder.
The word "intensifying" means those screens which intensify the effect of X-rays on the film.
When irradiated wit X-rays those films emit light, whose intensity is proportional to exposure
rate of activating X-rays.
Intensifying screen usually pairs and its thickness about 380 um.
Action
✓ Two intensifying screens are used, one in front of the film and the other at the back.
✓ The front screen absorbs low energy X-ray photons, an back screen absorbs the high
energy photons.
✓ Both screens are efficient in stopping the transmitted X-ray beam, and converting them
into visible light by photoelectric effect.
✓ One X-ray photon produces many light photons which will affected a relatively large
area of film emulsion.
✓ The amount of radiation required is reduced but at the coast of fine image detail.
Resolution is also decreased.
✓ Ultraviolet system improve resolution by reducing light diffusion and having virtually
no light crossover through the plastic film base.
Ideal requirements of intensifying screen
 It should have high attenuation co-efficient.
 Higher efficiency to convert X-ray beam to visible light.
 It should have low refractive index.
 It should be easy for handling.
 There should be short time for fluorescent decay.
 It should be cost-effective.
 There should be optimum thickness of screen to be used.

composition
protective coating

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 ❖ The transparent layer of the screen is closest to the X-ray film.
❖ It is of 15-25 um in size.
❖ It is made up of plastic largely composed of cellulose compound which is mixed with
polymer.
❖ Function
Physical protection resistant to the abrasion and damage by handling.
Prevention of static electricity.
It provide a surface for routine cleaning without disturbing the active phosphors.

Phosphor material
It is composed of phosphorescent crystals suspended in polymeric binder. 3 main phosphor
material are used in intensifying screen i.e. calcium tungstate. Rare earth phosphors including
gadolinium and lanthanum, yttrium. In some cases other phosphors are used like zinc sulphide
and barium lead phosphate.
Thickness of phosphours layer is about 40-100 um.
Characteristics of phosphorus material:
• High atomic number
• Emission of light
• Wavelength of light
• Absorption of X-rays
Reflective layer
o Between the luminescent and the base thickness approximately 25 um.
o It is made of shiny substance such as magnesium oxide or titanium dioxide.
o When X-ray interact with the active phosphor, light is emitted in all directions. Less
than half of the light is emitted in the direction of film. The reflective layer intercepts
light headed in other direction and redirects it to the film, so it increases efficiency of
the intensifying screen and some degrees of unsharpness occurring due to divergence of
light.
Base
✓ It is the layer farthest from the film.
✓ It is 1mm or 250 um thick.
✓ It serves as mechanical support for the phosphor layer.
✓ It is made up of high grade cardboard polyester or metal.
✓ It should be chemically inert, flexible, and should not contain impuities and should be
moisture resistant.
Screen speed
It is the time taken by the screen to emit light following exposure to X-ray. The faster the
screen the lower the radiation dose to the patient.
 Detail or fine (100)

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  Fast detail or medium (200)
 Rapid or fast (400)
 Super rapid (800)
Facte affecting speed of the film
1. Intrinsic factors
✓ Phosphor composition
✓ Phosphor thickness
✓ Crystal size
✓ Reflective layer
✓ Light absorbing dye
2. Extrinsic factors
o Temperature
o Kilovoltage
Advantages of intensifying screen
✓ Reduction of patient dose
✓ Less development time of the film.
✓ More sensitive to film
Disadvantages of intensifying screen
 They have lower resolution
 Mottling occurs due to non-uniformity in coating of the fluorescent chemicals
 Failure of reciprocity law
 Unsharp image
Lead intensifying screen
These are used only at higher kVp, as with 250kVp X-ray or cobalt-60 gamma rays.
Their intensification factor is about 2-3.
The absorption of X-ray by screen results in production of fast moving electrons, which
produce the latent image.
The front screen is about 0.1mm and back screen 0.15 mm thick.
Cassette
It is high proof holder that contains the screen and film. It is advice that is used to hold the
extraoral film and the intensifying screen.
Cassette are made in variety of shape and size, smallest cassette used to lateral oplique, and
biggest one to panoramic radiography.
Requirement of cassette
It should be heavy for the ease of handling.
It should be strong enough to withstand duty rough handling.
It should be easily handled in the diminished light setting of a darkroom.
It should have smooth outline and rough conrner.
Types
❖ Rigid type
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 ❖ Flexible type
❖ Gridded cassette
❖ Curved cassette
Construction
Light proof aluminium or carbon fiber container with Radiographic film sandwiched tightly
between two intensifying screens.
Exposure side of cassette
It is radiolucent. It should be made up of a material with low atomic number such as plastic or
cardboard and should be thin and sturdy.
Marking on the cassette
The cassette must be marked to orient the finished radiograph, a metal letter R or L is attached
to front to indicate the patient side
Function
 It maintains the film in close contact with the screen.
 It prevent light exposure.
 It protects intensifying screen from physical damage.

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 cephalometric radiograph

A cephalometric x-ray, also simply known as a ceph, is a diagnostic radiography,as a

standardized and radiographic form of skull radiography used extensively in orthodontics to assist
the relationships of the teeth to the jaws and the jaws to the rest of the facial skeleton.
Standardization was essential for the development, the measurement and comparison of specific
points, distances and lines within the facial skeleton, which is now an integral part of orthodontic
assessment. The greatest value is probably obtained from these radiographs if they are traces or
digitized and this is essential when they are used for the monitoring of treatment progress.

Cephalometric x-rays are also used by otolaryngologists -- doctors who specialize in the
treatment of ear, nose and throat disorders such as sleep apnea because these x-rays provide a
view of the patient's airways.

A radiograph of the head taken in a Cephalometer (Cephalostat) that is a head-holding device

introduced in 1931 by B. H. Broadbent in the USA and by H. Hofrath in Germany. The original
design included two ear rods for insertion into the external auditory canals, an infraorbital pointer
and a forehead clamp, to achieve parallelism of the Frankfort plane with the floor. The concept
of natural head position was introduced by C. F. A. Moorrees and M. R Kean in 1958 and now is
a common method of head orientation for cephalometric radiography.

Aims of Practical
a)To enable the identification of cephalometric points and planes used in orthodontic diagnosis
and treatment planning.
b)To trace 2 lateral skull radiographs (before and after treatment) of orthodontic treatment using
a functional appliance and to identify the changes achieved (if any).
Main indications:
1. orthodontic treatment
2. orthognathic srgey
Orthodontics:
1) Intial diagnosis confirmation of the underlying skeletal and or soft tissue abnormalities.
2) Treatment planning.
3) Monitoring treatment progress e,g, to assess anchorage requirements and incisor
inclination.
4) Appraisal of treatment result e.g. 1 or 2 months before the completion of active treatment
to ensure that treatment targets have been met and to allow planning of retention.
Orthognatic surgery:
1) Preoperative evaluation of skeletal and soft tissue patterns
2) To assist in treatment planning
3) Postoperative appraisal of the results of

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 4) Postoperarive appraisal of the resuls of sugery and long term follow up studies.

Equipment
Several different types of are available for cephalometric radiography, either as seprate units, or
as additiona; attachment, the patients are seated, while in thes they remain standing. Despite these
variables the essential requirements for this type of equipment are the same and include:
A. Head positioning and stabilizing apparatus with ear rods to ensure a standardized patient
postion (some units also have infraorbital guide rods).
B. Fixed anti-scatter grid to stop photons scattere within the patient reaching the film and
degrading the final image.
C. Cassette holder:
1. Cassette (usually 18*24 cm) containing intensifying screens and indirect action film.
2. Aluminium wedges filter. This is either part of ceohalosat and positioned between
the patient and the anterior part of the cassette, or it is attached to the tubehead,
covering the anterior part of the emerging beam. Its function is to attenuate the X=ray
selectively in the region of the facial soft tissue because these tissues are not dense
enough on their own to produce a visible radiographic shadow. This added attention
enable the soft tissue profile to be seen on the final radiograph.
D. X-ray generating apparatus that should be:
1. In a fixed position relative to the cephalostat (approx. 2 cm) and the film so that
successive radiographs are reproducible and comparable.
2. Capable of producing an X-ray beam that is:
a) Sufficiently penetrating to reach the film.
b) Parallel in nature to minimize magnification between R and L sides of the
mandible and to ensure that the midline points S, N and A are as sharp as
possible.
c) Collimated to an approximately triangular shape to restrict the area of the
patient irradiated to the required cranial base and facial skeleton, so avoiding
the skull vault and cervical spine.

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Concentrating on the patient's profile -- or side view of the head -- the x-ray technician positions
the patient according to specific criteria necessary when taking a cephalometric x-ray. The
exposure takes approximately 10 seconds and the x-ray is developed in approximately five to six
minutes. Most dental offices are equipped with the equipment necessary to take a cephalometric
x-ray.

Main radiographic projections

These include:
1. True cephalometric lateral skull
2. Cephalometric postero-anterior of the jaws
True cephalometric lateral skull
The terminology used lateral skull projection is somewhat confusing, the adjective true, as
opposed to oblique, being used to describe lateral skull projection when:
A. The film is parallel to the sagittal plane of the patient's head.
B. The X-ray beam is perpendicular to film and sagittal plane.
In addition, the word cephalometric should be include when describing the true lateral skull
radiograph taken in the cephalostat. This enables differentiation from the non-standardized true
lateral skull projection taken in a skull unit.

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The technique and position:

1. The patient is positioned within the cephalostat, with the sagittal plane of the head
vertical and parallel to the film and with the Frankfort plane horizontal. This positions the
patient with their head oriented at 90o to the X-Ray beam at a distance of 5ft (152.4 cm)
or 150 cm from the tube. The film is placed 15 inches from the head. The beam most
commonly enters on the patient’s right side, with the film cassette adjacent to the
patient’s left side (so that the patient’s head is oriented to the right on the radiograph), but
the reverse convention also is used.The teeth should generally be in maximum
intercuspation.
2. The head is immobilized carefully within the apparatus with the plastic ear rods being
inseted into the external auditory meati.
3. The aluminium wedge is positioned to cover the anterior part of the film.
4. The equipment is designed to ensure that when the patient is positioned correctly, the X-
ray beam is horizontal and centered on the ear rods.
To accomplish natural head position, the patient is asked to look into a mirror placed in front of
him/her at eye level (as if he/she were looking at the horizon), with the interpupillary line parallel
to the floor.

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Cephalometric postero-anterior of the jaws:
This projection is identical to the PA view of the jaws, that it is standardized and reproducible.
This makes it suitable for the assessment of facial asymmetries and for preoperative and
postoperative surgery involving the mandible.
Technique and positioning:
1. The head stabilizing apparatus of the cephalostat is rptated through 90 o.
2. The patient is positioned in the apparatus with the head tipped forwards and with the
radiographic baseline, i.e. in the forehead-nose position.
3. The head is immobilized within the apparatus by inserting the plastic ear rods ito the
external auditory meati.
4. The fixed X-ray beam is horizontal with the central ray centered through the cervical spine
at the level of the rami of the mandible.

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Tracing technique

The film is then traced and various standard landmarks, lines and angles are measured and
recorded. This allows comparison with normal values for a population and assessment of
growth and/or effects of treatment.
For the purposes of this practical we will use a set of analysis widely used in orthodontics. It is
known as 'Eastman Analysis'

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This should be undertaken in a darkened room. Use good quality tracing paper securely taped to
radiograph (along the top edge of the tracing paper, directly to the radiograph - this allows the
tracing paper to be lifted to examine the radiograph directly, yet replace it in the same place for
tracing)
Use a sharp (HB) pencil to outline the following :

1. Soft tissue profile of face (forehead to chin)

2. Sella turcica
3. Frontal bone and nasal bone
4. Orbital floor
5. External auditory meatus
6. Maxilla, upper lst molar and upper central incisor
7. Mandible, mandibular symphysis, lower lst molar and lower central incisor

Cephalometric landmarks

Readily recognizable points on a cephalometric radiograph or tracing, representing certain hard

or soft tissue anatomical structures (anatomical landmarks) or intersections of lines (constructed
landmarks). Landmarks are used as reference points for the construction of various
cephalometric lines or planes and for subsequent numerical determination of cephalometric
measurements.

Next Identify and mark the following cephalometric points:

S Sella: Mid point of sella turcica

N Nasion: Most anterior point on fronto-nasal suture
Or Orbitale: Most inferior anterior point on margin of orbit
Po Porion: Upper most point on bony external auditory meatus
ANS Anterior Nasal Spine
PNS Posterior Nasal Spine
Go Gonion: Most posterior inferior point on angle of mandible
Me Menton: Lower most point on the mandibular symphysis
A point: Position of deepest concavity on anterior profile of maxilla
B point: Position of deepest concavity on anterior profile of mandibular symphysis

Then draw in the following lines/planes

Frankfort Plane Po - Or Equivalent to the true horizontal when patient is standing upright.

Maxillary Plane PNS - ANS Gives inclination of maxilla relative to other lines/planes.
Mandibular Plan Go - Me Gives inclination of mandible relative to other lines/planes.

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The angle MMPA - Maxilla to Mandibular Planes Angle (Maxillary plane to Mandibular
plane) Gives an inclination of the maxilla relative to the mandible, this in turn indicates the
relative proportions of face height and acts as an indicator for future growth direction.

S - N Line: Indicates orientation of anterior cranial base.

N - A indicates relative position of maxilla the cranial base
N - B indicates relative position of maxilla the cranial base

The angles SNA; SNB; ANB indicates relative position of maxilla/mandible to each other and
to the cranial base

Long axis of upper central incisor/lower central incisor (root apex to incisal edge) - allows
measurement of the angulation of incisors to maxilla/mandibular planes.

Ricketts Anatomical Tracing

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Ricketts Points and Planes

Ricketts Frontal Anatomy

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Digital radiography is performed by a system consisting of the following functional components:
• A digital image receptor
• A digital image processing unit
• An image management system
• Image and data storage devices
• Interface to a patient information system
• A communications network
• A display device with viewer operated controls
In this and other modules, each of these components will be considered and detail. At this time
we will briefly introduce the various components.

The digital receptor is the device that intercepts the x-ray beam after it has passed through the
patients body and produces an image in digital form, that is, a matrix of pixels, each with a
numerical value.
This replaces the cassette containing intensifying screens and film that is used in non-digital, film-
screen radiography.
As we will soon see, there are several different types of digital radiography receptors.

Image management is a function performed by the computer system associated with the digital
radiography process.
These functions consist of controlling the movement of the images among the other components
and associating other data and information with the images.
Some of these functions might be performed by the computer component of a specific digital
radiography device or by a more extensive Digital Image Management System (DIMS) that serves
many imaging devices within a facility. Note: it is not unusual for the DIMS to be referred to by
an older, and somewhat less appropriate name, PACS (Picture Archiving and Communications
System).

The Patient Information System, perhaps known as the Radiology Information System (RIS), is
an adjunct to the basic digital radiography system. Through the interface, information such as
patient ID, scheduling, actual procedures performed, etc is transferred.

One of the major advantages of digital radiography is the ability to process the images after they
are recorded.
Various forms of digital processing can be used to change the characteristics of the digital images.
For digital radiographs the ability to change and optimize the contrast is of great value.
It is also possible to use digital processing to enhance visibility of detail in some radiographs.
The various processing methods are explored in much more detail in another module.

Digital radiographs, and other digital medical images, are stored as digital data.
Advantages (compared to images recorded on film) include:
• Rapid storage and retrieval
• Less physical storage space required
• Ability to copy and duplicate without loss of image quality.

The digital image storage methods and process is explored in more detail in another module.

Another advantage of digital images is the ability to transfer them from one location to another
very rapidly.
This can be:
• Within the imaging facility to the storage and display devices
• To other locations (Teleradiology)
 • Anywhere in the world (by means of the internet)
The total network available for transferring digital images is made up of a variety of integrated
systems as will be described in another module.

Compared to radiographs recorded and displayed on film, i.e. "softcopy", there are advantages of
"softcopy" displays.
One major advantage is the ability of the viewer to adjust and optimize image characteristics such
as contrast.
Other advantages include the ability to zoom, compare multiple images, and perform a variety of
analytical functions while viewing the images.
Digital x-rays reduce radiation 80-90% compared to the already low exposure of traditional dental
x-rays.

We can think of the direct digital radiographic receptor as "a digital x-ray camera".
The receptor is in the form of a matrix of many individual pixel elements. They are based on a
combination of several different technologies, but all have this common characteristic.
when the pixel area is exposed by the x-ray beam (after passing through the patient's body), the
x-ray photons are absorbed and the energy produces an electrical signal. This signal is a form of
analog data that is then converted into a digital number and stored as one pixel in the image.
Stimualible Phosphor Radiographic Receptor
We can think of the stimualible phosphor receptor as being like a conventional radiographic
intensifying screen in that it absorbs the x-ray photons and then produces light.
The difference is that there is a delay between the x-ray exposure and the production of the
light. This is how it works:
• First, a receptor (cassette) containing only a stimualible phosphor screen is exposed to
record an image. At this stage the image recorded by the screen is an invisible latent
image.
• The next step is to process the receptor through the reader and processing unit. In this
unit the screen is scanned by a very small laser beam. When the laser beam strikes a spot
on the screen it causes light to be produced (the stimulation process). The light that is
produced is proportional to the x-ray exposure to that specific spot. The result is that an
image in the form of light is produced on the surface of the stimualible phosphor screen.
A light detector measures the light and sends the data on to produce a digitized image.
Image Formation
As the surface of the stimualible phosphor screen is scanned by the laser beam, the analog data
representing the brightness of the light at each point is converted into digital values for each pixel
and stored in the computer memory as a digital image.

Digital Radiography Quality Characteristics

Like all medical images, digital radiographs have the five specific quality characteristics as we
see here .
We will now see how three of these, contrast, detail, and noise are effected by the characteristics
and operation of the digital system.