Dentomaxillofacial Radiology (2009) 38, 413–420

’ 2009 The British Institute of Radiology

http://dmfr.birjournals.org

SHORT COMMUNICATION
Collimator with filtration compensator: clinical adaptation to
meet European Union recommendation 4F on radiological
protection for dental radiography
M Alcaraz*,1, MC Garcı́a-Vera2, LA Bravo2, Y Martı́nez-Beneyto2, D Armero3, JJ Morant4
and M Canteras5
1
Department of Radiology and Physical Medicine, Faculty of Medicine/Dentistry, University of Murcia, Murcia, Spain;
2
Department of Stomatology, Faculty of Medicine/Dentistry, University of Murcia, Murcia, Spain; 3Department of Nursing and
Faculty of Medicine/Dentistry, University of Murcia, Murcia, Spain; 4Department of Medical Physics, University Rovira i Virgili,
Tarragona, Spain; 5Department of Biostatistics, Faculty of Medicine/Dentistry, University of Murcia, Murcia, Spain

Objective: Our aim was to develop a compensated filtration collimator for use in paediatric
patients undergoing cephalometric radiography that reduces the radiation dose administered
and fulfils recommendation 4F of the European guidelines on radiation protection in dental
radiology.
Methods: An easy to use filtration-compensated collimator was constructed of plastic, lead
and aluminium and used randomly with a group of 32 children (mean age 11 years)
undergoing cephalometric radiography before receiving orthodontic treatment. The radiation
doses administered to patients (eye lens and thyroid, submandibular and parotid glands) and
to the chassis of the radiographic equipment were determined.
Results: The filtration-compensated collimator is easily fixed to the external surface of the
radiographic equipment and results in (a) as collimator, a reduction of 40% in the surface
irradiated in the children and of 61.4% in the dose administered to the thyroid glands
(P,0.001); (b) as filtration compensator, a reduction of 32.8% administered to the eye lens
(P,0.001), 31.45% to the submaxillary gland (P,0.01) and 11.4% to the parotid gland
(P,0.05); there was no difference in the dose determined on the radiographic film.
Conclusions: A radiographic examination can be carried out with children using only a third
of the dose normally used with no increase in the time or cost involved.
Dentomaxillofacial Radiology (2009) 38, 413–420. doi: 10.1259/dmfr/15580890

Keywords: radiography; dental; radiation dosage; cephalometric; collimation

Introduction

Lateral cephalometric radiography (also known as skull
lateral teleradiography) is the most widely used radio-
graphic examination in orthodontic diagnosis and
therapy, as well as in the study of dental occlusion,
skeletal growth pattern and the sagittal relationship of
the jaws.1
Cephalometry traditionally produces images of the
entire head and much of the cervical spine. However,
the area of interest to orthodontists usually stops at the
level of the base of the skull. A British Orthodontic
*Correspondence to: Miguel Alcaraz, Department of Radiology and Physical
Medicine, Faculty of Medicine/Dentistry, University of Murcia, 30100 –
Campus de Espinardo, Spain; E-mail: mab@um.es
Received 28 May 2008; revised 17 September 2008; accepted 29 September 2008
Society working group supported the concept of the
reduction of lateral cephalogram dosage by using
modified wedge collimation to remove part of the skull
from the diagnostic area.2–5 Accordingly, the EU has
incorporated recommendation 4F in the European
guidelines on radiation protection in dental radiology:6
‘‘Where possible, lateral cephalograms should be
collimated to limit the field to the area required for
diagnosis. Manufacturers must incorporate this feature
into the design of cephalographic equipment’’. The
download is available from the European Commission
website (http://ec.europa.eu/energy/nuclear/radiopro-
tection/publication/doc/136_en.pdf).
Although such collimation should significantly reduce
patient dose, the manufacturers of cephalometric
 4F:clinical adaptation
414 M Alcaraz et al
equipment have not yet included this form of collimation
as standard,6 and, anyway, it is clear that equipment
manufactured prior to the recommendation and still in
use will not incorporate collimation systems that protect
the organs of children submitted to such radiological
examinations.7,8
Our aim was to make a compensated filtration
collimator (CFC) adapted for use with children under-
going cephalographic radiography to reduce the radia-
tion dose administered to the patient and to fulfil
recommendation 4F of the European guidelines on
radiation protection in dental radiology.
Materials and methods
Experimental cephalometric radiography
The conventional cephalometric radiographs (CRs)
were taken with a Philips Planmeca 2002 Proline
(Planmeca, Helsinki, Finland), using Kodak T-Mat G
film and Regular Kodak Lanex (Kodak, Valencia,
Spain) intensifying screens. The exposure settings were
62–68 kV, 6–12 mA and 0.4–0.6 s. The processing was
automatic with a Dürr Dental AC 245L (31 ˚C, 8 min)
(DÜRRH, Bietigheim-Bissingen, Germany). All radio-
graphic examinations were performed at a focus–film
distance of 160 cm, with the left side of the skull facing
the tube. The human skull was positioned by means of
ear plugs. All radiological examinations were per-
formed according to daily practice, ensuring an image
quality appropriate for all diagnostic needs, according
to Schultze et al.9
Cephalometric radiography clinic
With the approval of the University of Murcia Bioethical
Committee (Murcia, Spain: PI052823), 32 patients were
randomly selected from those referred to the Department
of Oral Radiology, University of Murcia Dental
Hospital, for lateral cephalograms prior to orthodontic
treatment: 16 lateral cephalograms were performed
according to daily practice and another 16 using the
collimation–filtration compensator were analysed.
Dosimetry
The absorbed doses were measured by using a set of 700
individually calibrated thermoluminescent dosemeters
(TLDs) (GR-200r; Conqueror Electronics Technology
Co., Beijing, China) supplied and read by the
Environmental Energy and Technological Research
Council of the Spanish Ministry of Industry and
Technology (CIEMAT). The dosemeters were placed
in the housing of the filtration-compensated collimator
and behind different parts of the same (anterior, middle
and posterior) and on the children’s skin facing the X-
ray tube (eye lens and thyroid, submandibular and
parotid glands).
The degree of dependence and correlation between
variables was assessed by an ANOVA, complemented by
Dentomaxillofacial Radiology
a comparison of means using the minimum significant
difference method (P,0.05). Quantitative means were
compared by regression and linear correlation analysis.
Results
The experimental phase permitted us to manufacture a
collimator with compensated filtration composed of a
plastic base, 3-mm-thick lead plates and several 0.2-
mm-thick aluminium sheets that can be fixed to the
chassis of the radiological equipment with Sellotape so
that the luminous signal of the machine coincides with
the line on the compensated filtration collimator
(Figure 1). The characteristics of the collimator, its
measurements and thicknesses can be seen in Figure 2.
Modifications in the radiological image of the cranium
produced by the successive superposition of the
different lead and aluminium layers can be observed
in Figure 3. The doses of radiation determined on the
different zones of the experimental collimator and the
reduction in radiation obtained in its clinical position
can be seen in Table 1.
The doses of radiation administered to the children’s
skin closest to the X-ray tubes (eye lens and thyroid,
submandibular and parotid glands) can be seen in
Table 2, and the statistical significance of the different
doses are shown in Table 3. The results point to a
significant reduction in the dose absorbed by the eye
lens (32.8%, P,0.001) and thyroid (61.4%, P,0.001)
and submandibular (31.4%, P,0.001) and parotid
(11.4%, P,0.05) glands. The overall reduction in the
dose administered to the children when the compen-
sated filtration collimator was being used was 34.2%
(Table 2).
Figure 4 shows two CRs obtained using the usual
technique and the CFC (2 kV more). The tissues
irradiated with the usual technique represented
432 cm2 on the radiographic image, which was reduced
by 40% (to 258.9 cm2) when the compensated filtration
collimator was used because most of the cerebral
hemispheres, spinal cord, neck and thyroid gland were
excluded.
The radiation doses determined on the surface of the
radiographic equipment surface facing the X-ray tube,
which contains the radiographic films using the CFC,
showed no statistically significant differences from the
doses determined without the same (Table 4).
Discussion
The CR provides a diagnostic image of a physical part
of the patient composed of structures of different
atomic numbers, densities and thicknesses. We have
attempted to compensate for biological differences, and
the physical characteristics of a radiation beam and its
anodic effect, by incorporating different thicknesses of

Figure 1 Collimator with filtration compensator: positioning on radiographic equipment
aluminium to adjust the absorption of the radiation for
photoelectric effect with the children’s heads (compen-
sated filtration). At the same time, the layers of lead are
adapting the shape of the beam to the paediatric skull/
head size to obtain only the image of the structures of
orthodontic interest.
Several authors have expressed concern over the
unsuitability of common radiological techniques for
use with children.1 Adaptation to the child’s age means
modifying equipment, materials and work practices,
especially when high doses or frequent examinations are
involved. Substantial reductions in the doses adminis-
tered to children have been attained in recent years by
diminishing radiation exposure fields, reducing the
exposure parameters to the volumes considered suitable
for children10–12 or increasing filtration levels by
incorporating layers of aluminium between the primary
radiation beam and the child.11,13,14 In this respect,
increasing the filtration of the pre-patient radiation
beam by using 3 mm of aluminium for small children
undergoing digestive radiological exploration with bar-
ium contrast has achieved a substantial reduction in the
doses administered, accompanied by hardly any reduc-
tion in the quality of the images obtained.
4F:clinical adaptation
M Alcaraz et al 415
However, although adapting collimation to diagnos-
tic needs reduces the patient’s dose, panoramic radio-
graphic machines which can carry out extraoral
radiographic procedures, such as CRs, do not include
these elements as standard or as an option at purchase.
Some equipment includes filters (not collimators) that
improve images of soft tissues during cephalometric
radiography,15,16 and others incorporate an extra
filtration between the patient and the chassis of the
film that makes it impossible to reduce the dose
absorbed by the patient.2,5,6 In light of this, some
authors have proposed different forms of collimation to
decrease the irradiation field in these machines.
We have managed to reduce the radiation field by
40%, protecting most of the encephalic tissue and
attempting to exclude the thyroid glands of the children
from the primary beam. Some authors describe greater
reductions in the radiation field than we have achieved,
ranging from 40%17, to 49%18,19 to 55%.1,20 However,
all have started with much larger radiation fields than
in our study, which are unlike those usually used for
children (using 24630 cm radiographic),17,21 or have
used phantoms1 which, lacking the anatomical diversity
of children, permit more precise collimation and a
Dentomaxillofacial Radiology
 4F:clinical adaptation
416 M Alcaraz et al

Anterior Posterior

3.1 cm
3 cm

11 cm
9.6 cm

6.5 cm
1 2 3 4 5
3.5 cm
0.6 cm

0.6 0.9
2 cm cm cm 2 cm 2.5 cm 2 cm 1 2 3 4 5

6 cm Thickness of each area

10 cm

Figure 2 Measurements and thicknesses of different zones of the collimator with filtration compensator: anterior, middle, posterior and
protected zones (1 and 5: 1 lead sheet; 2: 22 aluminium sheets; 3: 14 aluminium sheets; 4: gap)

Figure 3 Modification of the radiographic image obtained when gradually introducing laminas until the proposed degree of protection was
obtained

Dentomaxillofacial Radiology
 4F:clinical adaptation
M Alcaraz et al 417

Table 1 Radiation doses determined in different zones of the collimator with filtration compensator (CFC) during clinical application (dose in
mGy; mean of ten exposures).
Without CFC With CFC
Anterior Middle Posterior Protected
Doses (mGy (¡SD)) 1304.6¡30 94.6¡20 896¡40 1223.2¡30 25.3¡10
Reduction in doses (%) 100% 92.7% 31.3% 6.2% 98%
SD, standard deviation

greater reduction in the field exposed to radiation.
L’Abée and Tan (1982)22 even described a reduction of
77% in the exposed field, but only the facial skull
appears; a reduction of 85% was obtained when the
image was only of the maxillomandibular area.1
The doses determined in our study on the thyroid
gland without using the CFC are similar to those
described in clinical practice by several authors,23
although higher than those described when using
phantoms to simulate projection,1,24 mainly because the
exposure parameters were lower than we used (tube
potential, tube current and exposure time) and because in
our case the images were evaluated for their diagnostic
quality before initiating treatment (Table 4).
In this study, although we tried to ensure that the
thyroid gland always remained outside the irradiation
field, the reduction in the dose absorbed was only
61.4%, which means that the gland was not totally
excluded. While the thyroid of some children received a
dose of 2.2 mGy (corresponding to the dispersed
radiation resulting from the Compton effect during
exposure), in other children the dose was similar to that
received by children when the CFC was not used (the
gland remaining in the radiation field). It was therefore
not always possible to exclude the thyroid gland from
the zone irradiated during cephalometric radiography,
and it would have been necessary to make individual
modifications for each of the patients, increasing the
time necessary for the radiological exploration.
In practice, these differences in the irradiated field
mean only 1 cm differences in the length of the CFC,
but this is magnified during the radiological projection.

Table 2 Radiation dose determined on skin facing the X-rays tubes corresponding to the organs studied, with and without the compensated
filtration collimator (dose in mGy).
Eye lens Submandibular gland Parotid gland Thyroid gland
Child Without filter With filter Without filter With filter Without filter With filter Without filter With filter
1 68.2 – 143.0 – 201.0 – 129.0 –
2 – 51.7 – 112.0 – 203.0 – 23.0
3 100.0 – 135.0 – 145.5 – 123.0 –
4 – 85.0 – 122.0 – 107.0 – 121.0
5 144.0 – 113.6 – 123.1 – 122.4
6 – 92.0 – 48.7 – 111.0 – 112.5
7 145.2 – 62.7 – 177.2 – 115.0 –
8 – 117.0 – 20.0 – 138.7 – 20.0
9 114.4 – 178.2 – 198.0 – 176.0 –
10 – 52.8 – 139.7 – 200.0 – 15.4
11 106.0 – 116.6 – 114.2 – 117.7 –
12 – 65.9 – 51.7 – 131.8 – 22.0
13 77.0 – 119.9 – 148.5 – 136.4 –
14 – 31.0 – 18.7 – 110.0 – 14.3
15 55.0 – 86.9 – 204.6 – 128.7 –
16 – 36.3 – 40.7 – 149.6 – 28.6
17 105.0 – 27.5 – 112.2 – 92.4 –
18 – 64.9 – 61.6 – 129.8 – 96.8
19 133.1 – 151.8 – 178.2 – 86.9 –
20 – 138.6 – 58.3 – 139.7 – 2.2
21 13.2 – 96.8 – 122.1 – 125.4 –
22 – 5.5 – 118.8 – 110.0 – 115.5
23 102.0 145.0 110.2 130.0 –
24 – 87.0 – 114.0 – 127.8 – 26.0
25 142.0 – 133.0 – 194.0 – 179.0 –
26 – 90.0 – 120.0 – 196.0 – 18.4
27 80.0 – 87.9 – 180.2 – 131.0 –
28 – 34.0 – 41.7 – 135.7 – 25.0
29 111.4 – 95.8 – 119.1 – 123.7 –
30 49.8 – 117.8 – 107.0 – 23.6
31 67.2 – 65.7 – 206.6 – 128.0 –
32 – 50.7 – 23.0 – 151.6 – 126.0
Mean doses 97.7 65.7 109.9 75.5 158.4 140.5 127.7 49.3
Reduction in doses 32.8% 31.4% 11.4% 61.4%
Global reduction 34.2%

Dentomaxillofacial Radiology
 4F:clinical adaptation
418 M Alcaraz et al

Table 3 Significant differences obtained using the proposed compensated filtration collimator
Related differences t Degrees of P,
Organ Mean SD (statistical value) freedom Significance (bilateral)
Eye lens 32.0 20.5 6.229 15 0.001
Submandibular gland 34.5 38.5 3.584 15 0.01
Parotid gland 17.9 26.1 2.738 15 0.05
Thyroid gland 78.4 56.0 5.598 15 0.001
SD, standard deviation

The differences in the stage of development of children
at this age meant that the thyroid gland did not always
remain outside the field. It is not therefore easy during
the preparation of the patient to determine whether the
thyroid gland is inside the field or whether a lead
thyroid collar should be used to reduce the dose
administered/received.6 Recent reports have suggested
that the use of such a collar during cephalometric
radiography is associated with an increase in landmark
placement error; however, the collar is low cost and
easy to use.25
The radiation dose administered to the submandi-
bular gland during cephalometric radiography varies
from 39 mGy, in different phantoms,1 to 210 mGy, used
in real clinical examinations.18,19,21,23,24,26,27 In our
study, the dose to the submandibular gland fell within
this range, but was reduced by 31.4% when the CFC
was used. The fact that some reports suggest that a
collimator does not reduce the dose but may even
increase it by up to 15%1 can be taken as confirmation
that the compensated filtration unit of our collimator
reduced the dose received by the submandibular gland.

a b
Figure 4 Cephalometric radiographs obtained with (a) the usual technique and (b) using the compensated filtration collimator

Dentomaxillofacial Radiology
 4F:clinical adaptation
M Alcaraz et al 419

Table 4 Radiation doses determined on radiographic film in the three zones corresponding to the zones of the collimator filtration compensator
(CFC) (dose in mGy; mean of ten exposures)
Anterior zone Middle zone Posterior zone
Child Without CFC With CFC Without CFC With CFC Without CFC With CFC
1 34.1 26.4 38.5 33.0 31.9 23.1
2 41.8 36.3 29.7 23.1 33.9 28.2
3 35.2 25.3 39.6 31.9 29.2 24.6
4 40.7 37.4 28.6 24.2 35.7 31.7
5 34.6 25.9 39.0 32.5 37.1 32.6
6 41.5 36.8 29.2 23.6 36.2 29.6
Mean doses 37.9 31.3 34.1 28.0 34.0 28.3
Reduction doses 17.5% 17.9% 16.8%
Global reduction 17.4%

Several authors have reported that the radiation dose
administered to the skin covering the parotid gland
ranges between 35 mGy,1 on phantoms, and 2040 mGy,
in clinical practice.17 The dose we administered to the
parotid gland was higher than similar doses reported by
other authors;1,26,27 but despite this, we obtained a
reduction of 11.4% with the CFC. This is slightly less
than that obtained by Gijbels et al1 using a collimator
for a CR on a head phantom.
Similarly, authors have described doses to the eye
lens of between 12 mGy1 and 340 mGy,23 depending on
the characteristics of the exposure, the radiological
equipment used and the type of exposure (real or on
head phantoms). Our results without a collimator
resulted in intermediate doses in the range described
above, while a reduction of 32.8% was obtained with
the CFC by increasing the filtration of aluminium in
this zone. Gijbels et al1 recorded a decrease of 33%
administered to the eye lens on a radiological phantom
with collimation and no filtration, but the exposure
parameters were different to our case. However, we
think that the reduction in the dose received in our
study was basically due to the aluminium filter added.
The anatomical diversity of the patients meant that the
eye lens occasionally fell outside the thickest area of
aluminium and so was less protected than was desired.
We purposely carried out the study described here
using conventional radiological apparatus that had
been in use for many years. Therefore, comparative
studies of the doses administered to patients by digital
equipment may well point to much lower doses. For
example, a digital CR cuts the radiation dose reaching
the thyroid gland by 42%23 and that reaching the
submandibular gland by 35%.27 The advantage of using
the compensated filtration collimator is that it can also
be used with new digital equipment, in which the
reduction in dose would in absolute terms be similar.
We have found no references to the radiation doses
that reach the chassis of the radiographic equipment
during CR examinations (post-patient), although in our
opinion this dose is important for evaluating the final
result of the radiographic image. The dose determined
after passing through the patient (post-patient) and
reaching the different parts of the chassis corresponding
to the zones of compensated filtration were similar and
showed no statistically significant differences. These
results suggest that the compensator we used succeeded
in equalizing the radiation absorbed by the different
irradiated tissues, because the doses reaching the film
are similar in all three parts. This would also explain the
small effect that the CFC had on the radiological image
obtained.
A study of the radiographs obtained by orthodontists
showed them to be of good quality for the cephalo-
metric points to be interpreted. From a radiological
point of view, the images obtained with the CFC show
a slight diminution in contrast and a small loss of
resolution, but had no effect on the localization of the
cephalometric points necessary to undertake orthodon-
tic treatment (data not shown).28 These modifications
are similar to those described by several authors using
other radiological techniques, in which filtration was
increased by using aluminium to lower the dose of
radiation administered.29,30
The CFC used succeeded in diminishing the volume
irradiated by 40% and the irradiation of the tissues
necessary for correct interpretation of the image by
34.2%. The dose reduction by the use of both
collimation and filtration simultaneously translates into
a CR being obtained with 38.4% of the dose usually
used and an overall reduction of 61.6%. That is, the
radiation dose administered to a child represents a third
of what a child would normally receive. If we use other
parameters commonly used in radiological protection,
such as ‘‘dose–area’’ (integral of the doses in a section
of the beam axis), the dose used with the CFC is only
19% of that used in an examination carried out in
normal conditions. This parameter underlines the
combined reduction of the irradiation field and doses
administered to children.
Based on the results obtained, we recommend that
the elements described be incorporated in radiological
equipment for clinical use, especially for examinations
carried out in children, because, besides the benefits
described above, the proposed modification does not
involve any increase in examination time or in the costs
involved.
Acknowledgments
This report was supported with a grant from the National
Spanish R+D Programme of Council for Nuclear Security
(BOE no. 106,05/03/2007; res. CSN 24/09/2007).

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420 M Alcaraz et al
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