FACULTY OF DENTISTRY

DOCTOR OF DENTAL SURGERY

DENTAL RADIOLOGY-DD3:1304
By: Prof Dr Phrabhakaran (phrabhakaran@mahsa.edu.my)
BITEWING IMAGING (RADIOGRAPHY)
BITEWING IMAGING
(RADIOGRAPHY)
(EXAMINATIONS)
 Bitewing radiography takes the name
from the original technique which
required the patient to bite on a small
wing (tab) attached to an intraoral film
packet (on the pebbled surface).
Digital image receptors can be used and
the clinical indications are the same.
 An individual film is designed to show
the crowns of the premolar and molar
teeth on one side of the jaws.
BITEWING RADIOGRAPHY
 Main indications:
 -Detection and assessment of interproximal dental caries.
 Detection and assessment of the extent of occlusal caries.
 - Monitoring the progression of dental caries.
 - Assessment of existing restorations, discolored tooth with
suspicion of secondary caries.
 - Assessment of periodontal status; calculus deposits; chronic
resorption of the alveolar bone.
 - Pulp chamber shape and size; pulp stones.
 - Occlusal relationship of teeth??.

Specific indications for bitewing examination for new patients are:

 Presence of interconnected posterior proximal surfaces.
 Presence of posterior restorations .
Indication for Bitewing examination for recall patients is dependent
upon the patient’s caries and periodontal risk profile.
 5-80

positioning guide
The vertical angulation is always set
at (+) 5-8 degrees (the tubehead is
pointing downward). Make sure the
patient’s head is positioned properly
before attempting PID alignment.
(+) 5-80 vertical angulation is used to
compensate for the slight bend of the
upper portion of the film
and the tilt of the maxillary teeth-
curve of Monson (also to preclude
overlap of the cusps onto the occlusal
surface.
 Premolar Bitewing

 Two posterior bitewing views are

recommended for each
quadrant- a premolar and a
molar.

 For 12yrs old or younger, one

bitewing film is sufficient.

 Premolar bitewing covers the

distal half of the canines
(mandibular canine-more mesial)
and crowns of the premolars.
 Molar (posterior) bitewing

 Film is centered at the

2nd molar capturing 2
mm beyond the 3rd
molar.

The film was placed too far posterior.

Vertical Bitewing
Receptors

Vertical bitewings:
• the long axis of the film is
vertical: when there is moderate
to extensive alveolar bone loss.

• They can be performed both

anteriorly (2 for canines, 1 for
incisors) or posteriorly (premolar
and molar on each side).
IDEAL TECHNIQUE REQUIREMENTS

 1) The tab is positioned on the middle of the film and parallel

to the upper and lower edges of the film.
 2) The film should be positioned with its long axis
horizontally for a horizontal bitewing or vertically for vertical
bitewing.
 3) The posterior teeth and the film packet should be in
contact or as close together as possible.
 4) The posterior teeth and the film packet should be parallel-
the shape of the dental arch may necessitate two separate
film positions to achieve this requirements for the premolars
and the molars.
 5) In the horizontal plane the X-ray tubehead should be
aimed so that the beam meets the teeth and the film packet
at right angles, and passes directly through all the contact
areas.
 6) In the vertical plane, the X-ray tubehead should be aimed
downwards (approximately 5-8o to the horizontal) to
compensate for the curve of Monson.
 7) The position should be reproducible.
The film is placed in the mouth between the teeth and
the tongue. Hold on to the tab and instruct the patient
to close slowly and completely. Make sure the patient’s
head is against the headrest before aligning the x-ray
beam.
Patient and X-ray
Tubehead
 CONE

correct incorrect

The horizontal angulation is adjusted so that a line

connecting the front and back edge of the CONE (yellow line
above) is parallel with a line connecting the buccal surfaces
of the premolars and molars (green line above). Instruct the
patient to open their lips so that you can see the buccal
surface. Make sure they remain closed on the tab. The front
edge of the CONE should be anterior to the front edge of the
film.
POSITIONING TECHNIQUES

 1) Using a tab attached to the film packet

and aligning the X-ray tubehead by eye.

 2) Using a simple film holder to position the

film packet and receptor and facilitate the
positioning of the X-ray tubehead.
USING A TAB ATTACHED TO THE
FILM PACKET

 -Large film packets/phosphor plates (31

X 41mm) for adults (vertical or
horizontal).
 -Small film packets ( 22 X 35 mm) for
children under 12 years.
 -Longer film packet ( 53 X 26 mm) for
adults.
 Advantages:
 -simple
 -inexpensive
 -the tabs and plastic film covers are disposable, so no
extra cross-infection control procedures required.
 -can be used easily in children.
Disadvantages:
 - Arbitrary, operator dependent assessment of horizontal
and vertical angulation of the X-ray tubehead.
 - Radiographs are not accurately reproducible, so not
suitable for monitoring the progression of caries.
 - Coning off or cone-cutting of anterior part of film is
common.
 - The tongue can easily displace the film packet.
Cotton rolls can be used to help support the tab or
bitewing instrument incotton rollareas. As
edentulous
mentioned previously, the tab can also be moved
forward or backward on the film to get better tooth
support.
USING SIMPLE FILM
PACKET/SENSOR HOLDERS

Several simple film holders have been

produced. They can eliminate many of the
disadvantages of the arbitrary tab method.
The choice of holder is matter of personal
preference. 3 parts of the holder:
 - a mechanism for holding the receptor/film
packet parallel to the teeth.
 - a bite-platform that replaces the wing.
 - an X-ray beam aiming device (locator).
The film must be placed in the mouth as
showed in the diagram so that the film is incorrect
equidistant from the teeth along its entire
length (see above). The two placements
shown on right are incorrect, and will result
in overlapped proximal surfaces.

incorrect
Bite block can be
reversed
 Advantages:
 -Simple
 - Film packet held firmly and cannot be displaced by the tongue.
 - Position of the X-ray tubehead is determined by the holder, thus is
less operator dependent, ensuring that the X-ray beam is always at
right angles to the film packet.
 - Avoids cone cutting or coning off of anterior part of film.
 - Holders are autoclavable or disposable.

Disadvantages:
 -Position of the holder in the mouth is operator-dependent and not
accurately reproducible, so not suitable for monitoring progression
of caries.
 - Positioning of the film holder can be uncomfortable for the patient-
especially children.
 - Expensive holders.
 - Holders are not suitable for children.
FORESHORTENED
ELONGATED
OCCLUSAL
RADIOGRAPHY
(IMAGING)
Occlusal radiography is defined as those
intraoral radiographic techniques taken
using the film packet or digital phosphor
plate (57 X 76 mm) is placed in the
occlusal plane.

 Shows an area of teeth.

Useful for :
○ Locate the roots and supernumerary,
unerupted and impacted teeth (impacted
canine and third molars)
○ Localize foreign bodies in the jaws
(buccolingual position), stones in the salivary
duct.
○ Demonstrate the integrity of the maxillary
sinus.
○ Patients with limited mouth opening (trismus)
○ Give information about the location, nature,
extent and displacement of fractures of the
mandible and maxilla.
○ To detect disease in the palate or floor of the
mouth and determine lateral and medial
expansion of lesion.
65 degrees
Upper standard ( anterior)
occlusal
  Periapical assessment of the upper anterior teeth,
especially in children -adults who are unable to
tolerate periapical holders
 Detecting the presence of unerupted canines,
supernumeraries and odontomes.
 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 following trauma.
 As the midline view, when using the parallax
method for determining the bucco/palatal position
of unerupted canines
# 4 size film used in adults for
occlusal films. In the film at
right, the location of the
impacted canine is revealed.

# 2 size (PA) film used for

occlusal in children to image
anterior developing dentition
(see film at left)
Upper oblique occlusal

 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 affecting the
posterior maxilla
 Assessment of the condition of the antral floor
 As an aid to determining into the position of roots displaced
into the antrum during attempted extraction of upper
posterior teeth
 Assessment of fractures of the posterior teeth and
associated alveolar bone including the tuberosity
Floor of the nasal fossa

Floor of the maxillary antrum

Lower 45 (anterior) occlusal
o
 

This projection is taken to show the lower anterior

teeth and the anterior part of the mandible. The
resultant radiograph resembles a large bisected
angle technique periapical of the region.
 

 Periapical assessment of the lower incisor teeth

(fracture of teeth and alveolar bone)
 Evaluation of the size and extent of lesions such
as cysts or tumors affecting the anterior part of the
mandible
 Assessment of displacement fractures of the
anterior mandible in the vertical plane
 
  Lower 90 occlusal o

  

 Detection of the presence and position of

radiopaque calculi in the submandibular salivary
ducts
 Assessment of the bucco-lingual position of
unerupted mandibular teeth
 Evaluation of the bucco-lingual expansion of the
body of mandible by cysts, tumours or other bone
lesions
 Assement of displacement of fractures of the
anterior body of the mandible in the horizontal
plane.
Occlusal Radiography: Mandible

90 degrees

45 degrees
Lower oblique occlusal
 

This projection is designed to allow the image of

the submandibular salivary gland, on the side of
interest, to be project on to the film. However,
because the X-ray beam is oblique, all the
anatomical tissues shown are distorted.
 
 Detection of radiopaque calculi in the sub-
mandibular salivary gland of interest.
 Assesment of the bucco-lingual 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.
Interpretation of bitewing images

 1.     Presence of teeth and and location of:

                        - Occlusal caries
                        - Interproximal caries
 2.      Monitoring the progression of caries lesion (if previous
bitewing radiograph is available for comparison).
 3.      Conditions of existing restorations:  
 a.       presence of radiolucencies
 b.      Overhang
 c.       Depth of restoration
 4.      Assessment of crestal bone level and calculus deposits.
 5      Pulp chamber shape and size; pulp stones.
 6. Additional images (e.g. PA)