INTRAORAL PROJECTION

AND QUALITY EVALUATION

DENTAL RADIOLOGY 1
121221001
121221002
HILARIA REACHEL IRAWAN
NICHOLAS RAY WIJAYA GROUP
121221013
121221014
RIZKA AFFAN NABILA
AHMAD THARIQ BERMANI
MEMBERS
 INTRODUCTION
INTRAORAL X-RAYS (IMAGING TESTS) ARE THE BACKBONE OF IMAGING FOR GENERAL DENTISTS
INTRAORAL IMAGES CAN BE CLASSIFIED INTO THREE CATEGORIES:

(1) PERIAPICAL PROJECTIONS

(2) BITEWING PROJECTIONS
(3) OCCLUSAL PROJECTIONS

PERIAPICAL RADIOGRAPHS SHOULD SHOW ALL OF A TOOTH, INCLUDING THE SURROUNDING BONE. THE BITEWING IMAGE SHOWS ONLY THE CROWN AND
ADJACENT ALVEOLAR RIDGE THE OCCLUSAL IMAGE SHOWS A LARGER AREA OF ​TOOTH AND BONE THAN THE PERIAPICAL IMAGE. WHEN PROPERLY EXPOSED
AND PROPERLY PROCESSED, THESE PROJECTIONS CAN PROVIDE IMPORTANT DIAGNOSTIC INFORMATION THAT COMPLEMENTS CLINICAL EXAMINATION. AS
WITH ANY CLINICAL PROCEDURE, THE OPERATOR MUST HAVE A CLEAR UNDERSTANDING OF THE PURPOSE OF DENTAL RADIOGRAPHY AND THE CRITERIA FOR
EVALUATING THE QUALITY OF PERFORMANCE.
PERIAPICAL IMAGING
It describes intraoral techniques designed to show individual teeth and the tissues around the
apices. Each image usually shows two to four teeth and provides detailed information about the
teeth and the surrounding alveolar bone.

The main clinical indications for periapical radiography include:

Detection of apical infection/inflammation
Assessment of the periodontal status
Post trauma to the teeth and associated alveolar bone
Assessment of the presence and position of unerupted teeth
PERIAPICAL IMAGING

RADIOGRAPHIC TECHNIQUES
Not all of these optimal placement requirements can always be met due to the structure of the
mouth cavity. To address these issues, two periapical radiography approaches have been
developed:

Paralleling technique
Bisected angle technique.
PERIAPICAL IMAGING, PARALLEL TECHNIQUE

BASIC THEORY
1. The image receptor is positioned in the mouth parallel to the long axis of the tooth that is
being studied, and it is held in place.
2. After that, the X-ray tubehead is oriented at the tooth and the image receptor at right angles,
both horizontally and vertically.
3. The method is repeatable because it makes use of a film/sensor holder with set image
receptor and X-ray tubehead positions.

This positioning has the potential to satisfy four of the five ideal requirements mentioned earlier.
However, the anatomy of the palate and the shape of the arches mean that the tooth and the
image receptor cannot be both parallel and in contact.
PERIAPICAL IMAGING, PARALLEL TECHNIQUE

BASIC THEORY
A holder has been developed to aid in the usage of this technique. The different holders vary in
cost and design, but essentially consist of three basic components

A mechanism for holding the image receptor parallel to the teeth that also prevents bending
of the receptor
A bite block or platform
An X-ray beam-aiming device. This may or may not provide additional collimation of the
beam.

“ESSENTIALS OF DENTAL RADIOGRAPHY AND RADIOLOGY BY ERIC WHAITES, NICHOLAS DRAGE”

PERIAPICAL IMAGING, PARALLEL TECHNIQUE

GENERAL RECEPTOR HOLDER

Holder design that is being used depends upon whether the tooth under investigation is:
Anterior or posterior
In the mandible or maxilla
On the right or the left hand side of the jaw.

“ESSENTIALS OF DENTAL RADIOGRAPHY AND RADIOLOGY BY ERIC WHAITES, NICHOLAS DRAGE”

PERIAPICAL IMAGING, PARALLEL TECHNIQUE

Receptor Positioning
For optimal images, the receptor should be positioned parallel to
the teeth and placed deep in the patient's mouth. This is
particularly crucial when using rigid sensors, which may be larger
than film. In maxillary projections, the superior border of the
receptor typically rests at the height of the palatal vault in the
midline. Similarly, in mandibular projections, the receptor helps
displace the tongue posteriorly or toward the midline, allowing
the inferior border of the receptor to rest on the floor of the
mouth away from the lingual surface of the mandible. Placing the
receptor in the center of the mouth is ideal for patient
acceptance and comfort, especially with digital sensors.
PERIAPICAL IMAGING, PARALLEL TECHNIQUE

ANTERIOR

POSTERIOR
PERIAPICAL IMAGING, ANGLE BISECT

BASIC THEORY
1. The image receptor is placed as close to the tooth under investigation as possible without bending
the packet.
2. The angle formed between the long axis of the tooth and the long axis of the image receptor is
assessed and mentally bisected.
3. The X-ray tubehead is positioned at right angles to this bisecting line with the central ray of the
X-ray beam aimed through the tooth apex.
4. Using the geometrical principle of similar triangles, the actual length of the tooth in the mouth will
be equal to the length of the tooth on the image.
PERIAPICAL IMAGING, ANGLE BISECT

POSITIONING TECHNIQUES
The bisected angle technique can be performed either by using an image receptor holder to support the
image receptor in the patients mouth or by asking the patient to support the image receptor gently using
either an index finger or thumb. Both techniques are described.

Bisected Angle Instruments (BAI) closely resemble the paralleling technique holders and consist of the
same three basic components:
Image receptor holding mechanism
Bite block
X-ray beam-aiming
PERIAPICAL IMAGING, ANGLE BISECT
RECEPTOR, AND PLACEMENT USED FOR
BISECTING TECHNIQUE
The bisected angle technique can be performed either by using an image receptor holder to support the
image receptor in the patients mouth or by asking the patient to support the image receptor gently using
either an index finger or thumb. Both techniques are described.

Receptor used:
Anterior region: size 2 receptors are always placed in a vertical (upright) direction.
Posterior region: size 2 receptors are always placed in a horizontal (side) direction
Placement:
Positioned behind the area of interest, with the apical end against the mucosa of the lingual or palatal
surface
The occlusal or incisal edge is oriented towards the tooth with the receptor edge extending just
beyond the tooth.
PERIAPICAL IMAGING, ANGLE BISECT

ANTERIOR

POSTERIOR
COMPARISON OF THE PARALLELING AND BISECTED ANGLE TECHNIQUES
Advantages of the paralleling technique
Geometrically accurate images are produced
with little magnification.
The shadow of the zygomatic buttress
appears above the apices of the molar teeth.
The periodontal bone levels are well
represented.
The periapical tissues are accurately shown
with minimal foreshortening or elongation.
The crowns of the teeth are well shown
enabling the detection of approximal caries.
Disadvantages of the paralleling technique
Positioning of the image receptor can be very
uncomfortable for the patient, particularly
for posterior teeth, often causing gagging.
Positioning the holders within the mouth can
be difficult for inexperienced operators
particularly when using solid-state digital
sensors.
The anatomy of the mouth sometimes
makes the technique impossible, e.g. a
shallow, flat palate.
COMPARISON OF THE PARALLELING AND BISECTED ANGLE TECHNIQUES
Advantages of the bisected angle technique
Positioning of the image receptor is
reasonably comfortable for the patient in all
areas of the mouth.
Positioning is relatively simple and quick.
If all angulations are assessed correctly, the
image of the tooth will be the same length as
the tooth itself and should be adequate (but
not ideal) for most diagnostic purposes.
Disadvantages of the bisected angle technique
The many variables involved in the technique
often result in the image being badly
distorted.
Incorrect vertical tube head angulation will
result in foreshortening or elongation of the
image.
The periodontal bone levels are poorly shown.
The shadow of the zygomatic buttress
frequently overlies the roots of the upper
molars.
BITEWING

BITEWING RADIOGRAPHY
Bitewing radiographs take their name from the original technique which required the patient to bite on a small
wing attached to an intraoral film packet. Modern techniques use holders, as shown later, which have
eliminated the need for the wing (now termed a tab), and digital image receptors (solid-state or phosphor
plate) can be used instead of film, but the terminology and clinical indications have remained the same. An
individual image is designed to show the crowns of the premolar and molar teeth on one side of the jaws.

Main indications of this technique include:

Detection of lesions of caries
Monitoring the progression of dental caries
Assessment of existing restorations
Assessment of the periodontal status.
BITEWING

RECEPTOR STABILIZATION INSTRUMENT

BEAM ALIGNMENT DEVICE BITEWING TAB

Eliminates the need for the patient to Used when the beam alignment device
stabilize the receptor with a bitewing tab cannot be used.
BITEWING
INTRAORAL PROJECTION
A. Using tabs attached to the receptor
Select the appropriate size and orientation (vertical and horizontal) of the receptor
The patient is positioned with the head supported and with the occlusal plane horizontal.
Estimate the shape of the dental arch and the amount of film required
Insert the receptor into the lingual sulcus opposite the posterior teeth
The anterior edge of the receptor is positioned opposite the distal aspect of the lower canine, the
posterior edge just beyond the mesial aspect of the mandibular third molar.
BITEWING
INTRAORAL PROJECTION
A. Using tabs attached to the receptor
Tabs are placed on the occlusal surfaces of the mandibular teeth
The patient is asked to clench his teeth tightly on the tab.
As the patient closes the teeth, the operator pulls the tab firmly between the teeth to ensure that the
image receptor and the teeth touch.
Position the X-ray tube head so that the X-ray beam is directed directly through the contact area, at a
right angle to the tooth and receptor, approximately 5°–8° downward vertical angulation
Exposure is done
BITEWING
INTRAORAL PROJECTION
B. Using a receptor holder with a beam aiming device
Select a holder along with an appropriately sized receptor
The patient is positioned with the head supported and with the occlusal plane horizontal.
The holder is inserted into the lingual sulcus. The anterior edge of the receptor is positioned opposite the
distal aspect of the lower canine, the posterior edge just beyond the mesial aspect of the mandibular third
molar.
The patient is asked to clench the teeth firmly on the bite platform.
The X-ray tube head is aligned accurately using a Beam-alignment device
Exposure is done
BITEWING
EXAMPLES OF TYPICAL RIGHT AND LEFT
HORIZONTAL ADULT BITEWING
RADIOGRAPHS
OCCLUSAL

OCCLUSAL RADIOGRAPHY
Occlusal radiography is defined as those intraoral radiographic techniques taken using a dental X-ray set
where the image receptor (film packet or digital phosphor plate – 5.7 × 7.6 cm) is placed in the occlusal plane.
Suitable-sized solid-state digital sensors are not currently available.

Main indications of this technique include:

Periapical assessment of the upper anterior teeth, especially in children but also in adults unable to
tolerate periapical holders
Detecting the presence of unerupted canines, supernumeraries and odontomes
As the midline view, when using the parallax method for determining the bucco/palatal position of
unerupted canines.
Evaluation of the size and extent of lesions such as cysts or tumours in the anterior maxilla
Assessment of fractures of the anterior teeth and alveolar bone.
OCCLUSAL
MAXILLARY OCCLUSAL PROJECTION

1. Upper standard occlusal (standard occlusal): This projection shows the anterior part of the maxilla and
the upper anterior teeth

Main clinical indications

Examination of the periapical tissues of the upper anterior teeth
Detect unerupted canines, supernumerary teeth and odontoma.
As midline view
Evaluate the size and extent of lesions such as cysts and tumors in the anterior maxilla.
Examination of fractures of anterior teeth and alveolar bone.
OCCLUSAL
MAXILLARY OCCLUSAL PROJECTION
Upper standard occlusal (standard occlusal):

Technique and Positioning

The patient is seated with the head supported and with the occlusal plane horizontal and parallel to the
floor and asked to support the thyroid shield.
The image receptor, encased in a suitable barrier, is placed flush into the mouth up to the occlusal surface
of the lower teeth.
The X-ray tube head is positioned above the patient in the midline, pointing downward through the bridge
of the nose at an angle of 65-70° to the image receptor
OCCLUSAL
MAXILLARY OCCLUSAL PROJECTION

1. Upper oblique occlusal/oblique occlusal: This projection shows the posterior part of the maxilla and
the upper posterior teeth on one side.

Main clinical indications

Periapical assessment of the upper posterior teeth, especially in adults unable to tolerate periapical image
receptor holders
Evaluation of the size and extent of lesions such as cysts, tumors or other bone lesions affecting the
posterior maxilla
Assessment of the condition of the antral floor
As an aid to determining the position of roots displaced inadvertently into the antrum during attempted
extraction of upper posterior teeth
Assessment of fractures of the posterior teeth and associated alveolar bone including the tuberosity.
OCCLUSAL
MAXILLARY OCCLUSAL PROJECTION
Upper oblique occlusal/oblique occlusal:

Technique and Positioning

The patient is seated with the head supported and with the occlusal plane horizontal and parallel to the
floor.
The image receptor, suitably barrier wrapped, is inserted into the mouth on to the occlusal surfaces of the
lower teeth, with its long axis anteroposteriorly. It is placed to the side of the mouth under investigation,
and the patient is asked to bite together gently.
The X-ray tubehead is positioned to the side of the patients face, aiming downwards through the cheek at
an angle of 65–70° to the image receptor, centring on the region of interest
OCCLUSAL
MANDIBULAR OCCLUSAL PROJECTION

1. Lower 90°occlusal: This projection shows a plan view of the tooth-bearing portion of the mandible
and the floor of the mouth.

Main clinical indications

Detection of the presence and position of radiopaque calculi in the submandibular salivary ducts
Assessment of the buccolingual position of unerupted mandibular teeth
Evaluation of the buccolingual expansion of the body of the mandible by cysts/tumors
Assessment of fracture displacement of the anterior mandible in the horizontal plane
Assessment of mandibular width prior to implant placement.
OCCLUSAL
MANDIBULAR OCCLUSAL PROJECTION
Lower 90°occlusal

Technique and Positioning

The image receptor, suitably barrier-wrapped and facing downwards, is placed centrally into the mouth,
on to the occlusal surfaces of the lower teeth, with its long axis crossways. The patient is asked to bite
together gently.
The patient then leans forwards and then tips the head backward as far as is comfortable, where it is
supported.
The X-ray tube head, with circular collimator fitted, is placed below the patient’s chin, in the midline,
centering on an imaginary line joining the first molars, at an angle of 90° to the image receptor
OCCLUSAL
MANDIBULAR OCCLUSAL PROJECTION

1. Lower 45° (or anterior) occlusal: This projection is taken to show the lower anterior teeth and the
anterior part of the mandible.

Main clinical indications

Periapical assessment of the lower incisor teeth, is especially useful in adults and children unable to
tolerate periapical image receptor holders
Evaluation of the size and extent of lesions such as cysts or tumors affecting the anterior part of the
mandible
Assessment of fracture displacement of the anterior mandible in the vertical plane.
OCCLUSAL
MANDIBULAR OCCLUSAL PROJECTION
Lower 45°or anterior occlusal

Technique and Positioning

The patient is seated with the head supported and with the occlusal plane horizontal and par- allel to the
floor.
The image receptor, suitably barrier-wrapped and facing downwards, is placed centrally into the mouth,
onto the occlusal surfaces of the lower teeth, with its long axis anteroposteriorly, and the patient is asked
to bite gently together.
The X-ray tube head is positioned in the midline, centring through the chin point, at an angle of 45° to
the image receptor
OCCLUSAL
MANDIBULAR OCCLUSAL PROJECTION

1. Lower oblique occlusal: This projection is designed to allow the image of the submandibular salivary
gland, on the side of interest, to be projected onto the film. However, because the X-ray beam is
oblique, all the anatomical tissues shown are distorted.
Main clinical indications
Detection of radiopaque calculi in the sub- mandibular salivary gland of interest
Assessment of the buccolingual position of unerupted lower wisdom teeth
Evaluation of the extent and expansion of cysts, tumours or other bone lesions in the posterior part of
the body and angle of the mandible.
OCCLUSAL
MANDIBULAR OCCLUSAL PROJECTION
Lower oblique occlusal

Technique and Positioning

The image receptor, suitably barrier wrapped, and facing downwards, is inserted into the mouth, on to the
occlusal surfaces of the lower teeth, over to the side under investigation, with its long axis
anteroposteriorly. The patient is asked to bite together gently.
The patient’s head is supported, then rotated away from the side under investigation and the chin is
raised. This rotated positioning allows the subsequent positioning of the X-ray tubehead.
The X-ray tubehead with circular collimator is aimed upwards and forwards towards the image receptor,
from below and behind the angle of the mandible and parallel to the lingual surface of the mandible
OCCLUSAL
THANK YOU !