INTRAORAL RADIOGRAPHIC TECHNIQUE MANUAL Utilizing the Paralleling Principal Department of Oral Health & Diagnostic Sciences 3
A full mouth radiographic series (FMX) consists of 20 images composed of periapical (16) and bitewing (4) projections. Periapical radiographs are intended to evaluate the periapical region of the tooth and surrounding bone. Therefore, it is essential to obtain the full length of the tooth and at least 2 mm of periapical bone. Bitewing radiographs record, on a single image, the crowns and coronal 1/3 of the interproximal bone of both arches. Bitewings are useful for detecting interproximal carious lesions, bone height, pulp chamber size and shape, pulp stones, and overhangs on interproximal restorations. It is therefore essential to position the image receptor and x-ray beam so that there is an equal distribution of both arches in the resulting radiographic image. Instrument Assembly: The Rinn XCP Instrument for a full mouth series (FMX) of x-rays consists of 3 parts: 1. 3 biteblocks for the anterior, posterior, and bitewing set-ups. 2. 3 Indicator rods for the anterior, posterior, and bitewing set-ups. 3. 2 Aiming rings for the anterior, posterior, and bitewing set-ups. a. The same aiming ring is used for the anterior and bitewing set-ups 4
Posterior RINN set up for upper right and lower left and upper left and lower right, respectively Posterior RINN set up for Upper right and left respectively 5
Posterior RINN set up for Lower right and left respectively GENERAL RULE FOR PSP PLACEMENT IN RINN INSTRUMENTS: When you look through the aiming ring, you should ONLY see the sensitive side of the image receptor. The sensitive side is indicated by the black side of the PSP packet (see below images). 6
Videos are available that demonstrate proper operatory set-up, Rinn instrument assembly, and scanning of PSP plates. MAXILLARY CENTRAL-LATERAL PROJECTION Use a #1 size Photostimulable Phosphor (PSP) plate Center the PSP plate vertically in the anterior bite block with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. CORRECT POSITIONING OF THE PSP Center the CENTRAL-LATERAL INCISOR CONTACT on the PSP plate. Place the PSP plate as far back into the mouth as possible so that the PSP plate is as parallel as possible to the long axes of the teeth. This is accomplished by engaging the incisal edges of the incisors in the FIRST OR SECOND GROOVE of the biteblock. The first or second grooves are located on the outer edge of the biteblock (edge towards the source of radiation). Position the PSP-plate so that the appropriate contact will be open (central-lateral contact). This is accomplished by projecting the x-ray beam through the contact area/s of interest Press the holder against the MAXILLARY INCISORS FIRST, then have the patient gently bite together. NOTE: Sometimes, greater stability of the bite block may be achieved if a cotton roll is placed BETWEEN the biteblock and the MANDIBULAR TEETH before having the patient close. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. Resulting radiograph 1. The central-lateral contact should be centered in the image. 7
2. At least 2 mm of apical bone is visible above the root apex. 3. Central-lateral contact is open. MAXILLARY CANINE PROJECTION Use a #1 size Photostimulable Phosphor (PSP) plate Center the PSP plate vertically in the anterior biteblock with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. CORRECT POSITIONING OF THE PSP Center the CANINE in the middle of the PSP plate. Place the PSP plate well away from the palatal surface of the teeth so that the PSP plate is as parallel as possible to the long axis of the cuspid. o This is accomplished by engaging the incisal edge of the cuspid in the FIRST or SECOND GROOVE of the biteblock. Position the PSP-plate so that the appropriate contact will be open. o This is accomplished by projecting the x-ray beam through the contact area of interest. o Note: the contact to open is the lateral-canine contact. Do not attempt to open the distal canine contact; it will be visualized on different views. Press the holder against the canine FIRST, then have the patient gently bite together. NOTE: Sometimes greater stability of the biteblock may be achieved if a cotton roll is placed BETWEEN the biteblock and the MANDIBULAR TEETH before having the patient close. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. 8
Resulting Radiograph 1. The canine should be centered in the image. 2. At least 2 mm of apical bone is visible above the root apex. 3. The lateral-canine contact is open. MAXILLARY PREMOLAR PROJECTION Use a #2 size PSP plate. Center the PSP plate HORIZONTALLY in the posterior biteblock with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. CORRECT POSITIONING OF THE PSP Position the PSP plate near the midline of the palate to ensure that the PSP plate is placed as parallel as possible to the long axes of the premolars o This is accomplished by engaging the buccal cusps in the First or Second Groove of the bite block). The anterior edge of the PSP plate should be placed adjacent to the maxillary canine on 9
the side being radiographed so that the distal ½ of the canine will be included in the radiographic image. Position the PSP-plate so that the appropriate contacts will be open. o This is accomplished by projecting the x-ray beam through the contact areas of interest. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. Resulting Radiograph 1. The distal half of the canine should be visible as well as all of the first and second premolars and first molar and sometimes also the mesial half of the 2nd molar. 2. At least 2 mm of apical bone is visible above the root apex. 3. The contacts should be open. MAXILLARY MOLAR REGION Use a #2 size PSP plate. Center the PSP plate HORIZONTALLY in the posterior biteblock with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. 10
CORRECT POSITIONING OF THE PSP Orient the PSP plate so that it is as parallel as possible to the long axes of the teeth. o This is accomplished by placing the buccal cusps of the maxillary teeth in the FIRST or SECOND GROOVE of the biteblock. o This will place the upper edge of the PSP plate at or across the midline of the palate. Position the PSP-plate so that the appropriate contacts will be open. o This is accomplished by projecting the x-ray beam through the contact areas of interest. Position the PSP plate to cover the first, second, and third molar areas. The anterior border should just cover the distal aspect of the second premolar. o Note: the mesial placement of the edge of the PSP will usually NOT include any of the 1 st premolar. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. Resulting Radiograph 1. Radiograph should show all of the first, second, and third molar areas. 2. At least 2 mm of apical bone is visible above the root apex. 3. The contacts should be open. 11
MANDIBULAR CENTRAL-LATERAL PROJECTION Use a #1 size Photostimulable Phosphor (PSP) plate Center the PSP plate vertically in the anterior biteblock with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. CORRECT POSITIONING OF THE PSP Center the central-lateral contact in the middle of the PSP plate. Engage the biteblock against the INCISAL EDGES of the mandibular incisors in the vicinity of the center hole. The bottom edge of the PSP plate should be placed UNDER THE TONGUE extending posteriorly into the 2nd premolar-1st molar region. Position the PSP-plate so that the appropriate contact will be open. o This is accomplished by projecting the x-ray beam through the contact area of interest. ROTATE the PSP plate DOWNWARD into the floor of the mouth until it is as parallel as possible to the long axes of the incisors. Press lightly downward and backward on the PSP plate and biteblock to ensure that the holder maintains continuous contact with the incisal edges. Note: sometimes greater stability can be accomplished by placing a cotton roll BETWEEN the top of the biteblock and the MAXILLARY TEETH before having the patient close. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. Resulting Radiograph 1. The central-lateral contact should be centered in the image. 2. At least 2 mm of apical bone is visible below the root apex. 3. The central-lateral contact is open. 12
MANDIBULAR CANINE PROJECTION Use a #1 size Photostimulable Phosphor (PSP) plate Center the PSP vertically in the anterior biteblock with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. CORRECT POSITIONING OF THE PSP Center the canine in the middle of the PSP plate. The PSP plate is placed under the tongue and across the midline. Engage the biteblock against the INCISAL EDGE of the mandibular canine in the vicinity of the center hole. Position the PSP-plate so that the appropriate contact will be open. o This is accomplished by projecting the x-ray beam through the contact area of interest. o Note: the contact to open is the lateral-canine contact. Do not attempt to open the distal canine contact; it will be visualized on different views. ROTATE the PSP plate DOWNWARD into the floor of the mouth until it is as parallel as possible to the long axis of the canine. Press lightly downward and backward on the PSP plate holder to ensure that the biteblock maintains continuous contact with the incisal edge of the canine. Note: sometimes greater stability can be achieved by placing a cotton roll BETWEEN the top of the biteblock and the MAXILLARY TEETH before having the patient close. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. 13
Resulting Radiograph 1. The canine should be centered in the image. 2. At least 2 mm of apical bone is visible below the apex. 3. The lateral-canine contact is open MANDIBULAR PREMOLAR REGION Use a #2 size PSP plate. Center the PSP plate HORIZONTALLY in the posterior bite block with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. CORRECT POSITIONING OF THE PSP Insert the PSP plate and holder into the mouth and carry it past the central incisors to a point where the anterior edge of the PSP plate is adjacent to the mandibular canine on the side being radiographed. Adjust the PSP plate DOWNWARD past the lateral border of the tongue so that the bottom edge of the PSP plate will pass BETWEEN THE TEETH AND THE TONGUE. o Displace the PSP plate medially (toward the middle of the tongue) to make sure the bottom edge is not pressing against the muscle attachment for the floor of the mouth. The biteblock should rest on the MANDIBULAR occlusal surfaces near the center hole. The PSP plate should also be positioned parallel to the lingual surface of the mandibular 14
teeth. Position the PSP plate so that the appropriate contacts will be open. o This is accomplished by projecting the x-ray beam through the contact areas of interest. Ask the patient to gently close together and stabilize the holder, if necessary, with a cotton roll between the biteblock and the MAXILLARY TEETH. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. Resulting Radiograph 1. Radiograph should show the distal half of the cuspid, all of the first and second premolars, the first molar, and sometimes the mesial half of the 2nd molar. 2. At least 2 mm of apical bone is visible below the root apex. 3. The contacts should be open. MANDIBULAR MOLAR REGION Use a #2 size PSP plate. Center the PSP plate HORIZONTALLY in the posterior biteblock with the black dot in the groove (black dot in the slot) and the black side of the PSP packet towards the source of radiation. CORRECT POSITIONING OF THE PSP Insert the PSP plate and holder into the mouth and carry it past the central incisors to a point 15
where the anterior edge of the PSP plate is adjacent to the mandibular second premolar on the side being radiographed. Adjust the PSP plate DOWNWARD past the lateral border of the tongue so that the bottom edge will pass BETWEEN THE TEETH AND THE TONGUE. The bite block should rest on the MANDIBULAR occlusal surfaces near the center hole. Position the PSP-plate so that the appropriate contacts will be open. o This is accomplished by projecting the x-ray beam through the contact areas of interest. Ask the patient to gently close together and stabilize the biteblock, if necessary, with a cotton roll between the biteblock and the MAXILLARY TEETH. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. Resulting Radiograph 1. Radiograph should show the first, second and third molar areas. 2. At least 2 mm of apical bone is visible below the root apex. 3. The contacts should be open. PREMOLAR BITEWING PROJECTION (horizontal technique) Use a #2 size PSP plate. Center the PSP plate in the bitewing biteblock with the black side of the PSP packet towards the source of radiation. 16
CORRECT POSITIONING OF THE PSP Position the PSP plate so that its mesial edge will include the distal half of the mandibular canine. Holding onto the edge of the positioning device, place the biteblock in contact with the MANDIBULAR TEETH. Horizontally, position the PSP plate so that the x-ray beam is directed through the mandibular contacts. o There may be some difference in the curvature of the mandibular and maxillary arches. However, when the x-ray beam is accurately directed through the mandibular premolar contacts, overlapping is minimal or absent in the maxillary premolar segment. o Typically this projection requires a +10 angle of the BID (with the patient s occlusal plane parallel to the floor). Make sure that the PSP plate is BETWEEN the lingual surfaces of the teeth and the lateral border of the tongue. Slide the aiming ring down the indicator rod to approximate the skin surface before making the exposure. Resulting radiograph 1. Radiograph should show an equal distribution of both arches. 2. The distal half of the maxillary and mandibular canines should be visible as well as the 1 st and 2 nd premolars, 1 st molars and occasionally the second molars. 3. The contacts should be open 17
MOLAR BITEWING PROJECTION (horizontal technique) Place the PSP plate between the tongue and the teeth and far enough posteriorly to include the distal of the last erupted tooth in the arch. Typically this projection requires a +10 angle of the BID (with the patient s occlusal plane parallel to the floor). Horizontally, project the x-ray beam through the contact areas of interest. It is helpful to align the indicator rod with the maxillary contacts. Resulting Radiograph 1. Radiograph should show an equal distribution of both arches. 2. Radiograph should include the distal of the last erupted tooth in the arch. 3. The contacts should be open. 4. It is preferable to see the distal surfaces of the maxillary and mandibular second premolars. 18
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GRU RADIOGRAPHIC TECHNIQUE MAXILLARY ANTERIOR EXPOSURE Anterior Rinn Instrument, Use #1 PSP plate, place black dot in the slot, black side towards ring Patient s Mouth Open Center area of interest on biteblock Lean biteblock so that teeth are in 1 st or 2 nd groove If needed, place cotton roll under the biteblock touching the incisal edges of mandibular anterior teeth Patient s mouth closes Slide the aiming ring down the indicator rod to approximate the skin surface Place cone flush with ring and make exposure 20
MANDIBULAR ANTERIOR EXPOSURE Anterior Rinn Instrument Use #1 PSP plate, place black dot in the slot, black side towards ring Patient s Mouth Open Center area of interest on biteblock Lean biteblock so that teeth are in middle groove If needed, place cotton roll on top of the biteblock touching the maxillary teeth Patient s mouth closes Slide the aiming ring down the indicator rod to approximate the skin surface Place cone flush with ring and make exposure 21
MAXILLARY POSTERIOR EXPOSURE Posterior Rinn Instrument, Use #2 PSP plate, Place PSP plate horizontally in biteblock, place black dot in the slot, place black side towards ring Patient s Mouth Open Center area of interest on bite block Lean biteblock so that teeth are in 1 st or 2 nd groove Make PSP plate parallel to lingual of teeth If needed, place cotton roll below the biteblock touching the occlusal surfaces of mandibular posterior teeth Patient s mouth closes Slide the aiming ring down the indicator rod to approximate the skin surface Place cone flush with ring and make exposure 22
MANDIBULAR POSTERIOR EXPOSURE Posterior Rinn Instrument, Use #2 PSP plate, Place PSP plate horizontally in biteblock, place black dot in the slot, place black side towards ring Patient s Mouth Open Center area of interest on biteblock Lean biteblock so that teeth are in middle groove Make PSP plate parallel to lingual of teeth If needed, place cotton roll against occlusal surfaces of maxillary teeth Patient s mouth closes Slide the aiming ring down the indicator rod to approximate the skin surface Place cone flush with ring and make exposure 23
BITEWING EXPOSURE Rinn Bitewing Instrument, Use size #2 PSP plate, place PSP plate horizontally in holder, dot does not matter, black side towards ring Patient s Mouth Open Center area of interest on biteblock Place biteblock against mandibular teeth Align aiming arm with mandibular contacts (for premolar bitewing projection) Align aiming arm with maxillary contacts (for molar bitewing projection) Patient s mouth closes 24 Slide the aiming ring down the indicator rod (aiming arm) to approximate the skin surface Place cone flush with ring and make exposure
QUALITY EVALUATION CRITERIA GENERAL CHARACTERISTICS OF A QUALITY RADIOGRAPH IMAGE CONTRAST, DENSITY, SHARPNESS, IDENTIFICATION Radiographic image should permit differentiation between the various structures of the teeth, the periodontal ligament space, the lamina dura, the supporting bone and normal anatomic landmarks. IMAGE COVERAGE All crowns and roots, including apices, are fully depicted together with the interproximal alveolar crests, contact areas, and surrounding bone regions. IMAGE DEFECTS Images of all teeth and other structures are shown in proper relative size and contour with minimal distortion, without overlapping images where anatomically possible, and without partial images (cone cuts). ANATOMICAL ACCURACY A properly exposed radiograph is said to have anatomical accuracy when: 1. The labial and lingual cemento-enamel junctions of the anterior teeth are superimposed. 2. The buccal and lingual cusps of posterior teeth (especially the molars) are superimposed. 3. The contacts of the teeth are opened in at least one of the projections of a given area. 4. The buccal portion of the alveolar crest is superimposed over the lingual portion of the alveolar crest. 5. There is no superimposition of the zygomatic bone over the roots of the maxillary molar teeth. 25
EACH SPECIFIC REGION OF THE FMX SHOULD INCLUDE THE FOLLOWING: Maxillary molar area All crowns and roots of the maxillary molars including the apices are fully depicted together with the interproximal alveolar crests, contact areas and surrounding bone region. There is no superimposition of the lower border of the zygomatic bone over the roots of maxillary molars. The radiograph should include all of the first, second, and third molars (erupted or not) with open interproximal spaces. Maxillary premolar area All the crowns and roots of the maxillary premolars and first molar, including the apices, are fully depicted together with interproximal alveolar crests, contact areas and surrounding bone. In the maxillary premolar projection the distal surface (distal 1/2) of the canine must be seen. The contacts should be open. Maxillary canine area All of the crown and root of the maxillary canine, including the apex, is fully depicted together with the interproximal alveolar crest between the maxillary canine and the maxillary lateral incisor, the contact area and surrounding bone region. The lateral incisor - canine contact should be open but it is not necessary for the distal surface of the maxillary canine to be seen. The canine should be centered. 26
Maxillary central - lateral incisor area The central-lateral contact should be centered and open. The crowns and roots should be visible with at least 2 mm of bone visible beyond the apex. Mandibular molar area All crowns and roots, including apices, of all three mandibular molars, are fully depicted together with interproximal alveolar crests, contact areas and surrounding bone regions. Contacts should be open. Mandibular premolar area All the crowns and roots of the mandibular premolars, including the apices, are fully depicted together with interproximal alveolar crests, contact areas and surrounding bone regions. The distal surface (distal1/2) of the canine should be seen in this projection. Contacts should be open. 27
Mandibular canine area All of the crown and the root of the mandibular canine, including the apex, is fully depicted together with the interproximal alveolar crests and contact area between the mandibular lateral incisor and mandibular canine, and surrounding bone region. The canine should be centered. Lateral-canine contact should be open. Mandibular central - lateral incisor area All crowns and roots, including apices, of the central and lateral incisors, are fully depicted together with interproximal alveolar crests, contact areas and surrounding bone regions. The central - lateral incisor contact should be centered in the radiograph and should be open. Premolar bitewing All crowns of the maxillary and mandibular premolars are fully depicted together with the interproximal crests and contact areas. The distal surfaces of the maxillary and mandibular canines must be seen. The images are without horizontal overlap where anatomically possible. 28
Molar bitewing All crowns of the maxillary and mandibular molars are fully depicted together with the interproximal crests and contact areas. It is preferable to see the distal surfaces of the maxillary and mandibular second premolar teeth. The images are without horizontal overlap where anatomically possible. The distal of the last erupted tooth is visible. RADIOGRAPHIC MOUNTING PROCEDURES Mounting intraoral radiographs is a relatively simple procedure provided you have some knowledge of the normal radiographic anatomical landmarks for each region of the mouth and can recognize tooth morphology. Maxillary posterior regions: All maxillary posterior radiographs should be arranged so that the crowns of the teeth are toward the bottom of the computer screen and roots are towards the top (the same way they are positioned within the patient). If no radiographs were exposed backwards, once the maxillary posterior radiographs are oriented with the crowns downward, it will be necessary only to identify mesial or distal anatomic landmarks of teeth in order to distinguish right from left. Radiographs with the more mesial structures are mounted in the premolar position; those with more distal landmarks are mounted in the molar positions. Maxillary anterior region: Identify the four maxillary anterior radiographs and rotate the incisal portion of each image down toward the bottom of the computer screen (same as for maxillary posterior region). Use the anatomic landmarks of the nasal cavity, soft tissue of the nose, and maxillary sinus to help you distinguish between the maxillary and mandibular anterior periapical radiographs. Identify the maxillary central - lateral incisor radiographs and mount them in the center windows of the anterior section of the mount; next identify the R and L canine radiographs and mount them with mesial anatomic structures always directed toward the middle of the mount. 29
Mandibular posterior regions: Identify the four (4) posterior mandibular radiographs. Rotate these radiographs around until the coronal portion of the radiograph is directed toward the top of the computer screen. Identify mesial and distal structures and arrange in appropriate areas of the mount. Mandibular anterior region: Rotate the four mandibular anterior radiographs until their incisal edges are directed toward the top of the screen; identify the central - lateral incisor regions and mount them into the center windows of the mount. Next mount the canine projections. Bitewings: The remaining four radiographs are interproximal radiographs. Orient these radiographs with the curve of Spee (occlusal plane between maxillary and mandibular teeth) directed upward toward the distal. If the occlusal plane is flat attempt to identify characteristics of the respective crowns or frequently the bifurcation of the mandibular molar is distinguishable and may serve as a valuable aid in distinguishing mandibular from maxillary teeth. Once the appropriate arch can be identified the radiographs can be properly oriented with the most mesial structures used to identify right from left and premolar from molar regions. PATIENT'S RIGHT PATIENT'S LEFT Ex. mounted FMX 30