Indications for Films

Paralleling - recommended for all

periapical films.
Bisecting - used when paralleling not
effective (shallow floor of mouth, etc.)
Bitewing - identify interproximal caries,
alveolar crest
Occlusal – localize objects buccolingually
Panoramic – used for overall evaluation of
dentition. Best film for 3rd molars,
edentulous, trismus.
Number of films per technique
(All teeth present)

Ant Post
Par 7 - #1 8 - #2

Bis Ang 6 - #2 8 - #2

BW None 4 - #2

Vert-BW 3 - #2 4 - #2
# 0 for children with small mouths
Paralleling
Technique
Head Position

Head position for the paralleling technique is not critical,

since you will be aligning the PID with the ring. However,
since bitewing films are also taken on most patients, the
head should routinely be positioned as in the illustration
above (this is true when using bitewings with tabs). The
maxillary arch should be parallel to the floor, both side-to-
side and front-to-back. The head should always be
supported by the headrest.
 correct incorrect

In the paralleling technique, the film is positioned in the mouth

so that the long axis of the film and the long axis of the tooth
are parallel. We can not see the long axes of the teeth but, in
general, all the teeth incline toward the middle of the head.
Thus the film/instrument will almost always be tipped slightly
(up or down, depending on the arch). In the illustration above
right, the film is placed straight up and down and is not
parallel; the patient is unable to close completely on the
biteblock and the apices of the teeth would not appear on the
film.
Rinn XCP Paralleling Instruments

ANTERIOR POSTERIOR
 Anterior Periapical
Long axis of film (# 1 – adult; # 0 – small child) vertical. Colored
side against biteblock support; white side faces teeth/ring
(white-in-sight). Dot-end of film placed in slot of biteblock (dot-
in-the-slot).

slot dot
dot
 Posterior Periapical
Long axis of film (# 2 – adult, # 0 – small child) horizontal.
Colored side of film against biteblock support; white side
faces teeth/ring (white-in-sight). Dot-edge of film placed
in slot of biteblock (dot-in-the-slot).

slot
dot dot
 correct incorrect

In general, the film should be positioned a reasonable distance

away from the teeth in order to allow the patient to close
reasonably comfortably and still maintain the parallel
relationship between teeth and film. The film will be closest to
the teeth in the mandibular molar region.
Ideally, we would like to have the long axis of the film parallel
with the long axis of the tooth. If the palate or floor of the mouth
is too shallow, the film usually cannot be positioned in this
manner. By tipping the film (see illustration above), we can
effectively position the film in the patient’s mouth. As long as the
film is not tipped more than 20 degrees from the line indicating
the long axis of the tooth, the image will be OK.
Make sure the patient is biting completely on the
biteblock as in the illustration above left. Sometimes the
patient will close their lips around the biteblock, looking
like they are biting down, but the biteblock is not in
contact with the teeth you are x-raying (illustration above
right). Make sure you can see the teeth in contact by
having the patient open their lips slightly.
The film above right shows the result of the patient not
biting on the biteblock. The apices are cut off.
Once the patient is biting on the biteblock, support the
bar with the fingers of one hand while sliding the ring
down with the other hand. The ring should be close to
the face. This will slightly reduce the amount of
exposure to the patient’s face.
Cotton rolls can be helpful in supporting the biteblock
in edentulous regions or where a tooth is tipped or
supraerupted. The cotton roll is placed against the
opposing arch, not between the biteblock and the
teeth being radiographed.
 Maxillary Incisor

centered on contact between film placed far back in

central and lateral incisors patient’s mouth
 Maxillary Canine

film placed against the opposite

film centered on canine side of the arch, far away from
the canine
In the maxillary canine region especially, the film may tip to
one side or the other. A cotton roll is placed BETWEEN THE
BITEBLOCK AND THE MANDIBULAR TEETH (opposite arch) to
help keep the film aligned properly.
 Maxillary Premolar

film equidistant from lingual

front edge of film anterior to surfaces of teeth (red arrows);
middle of canine; approximately this opens contacts between
centered on 2nd premolar the teeth.

film in center of palate

 Maxillary Molar

film equidistant from lingual

film centered on
surfaces of teeth (red arrows);
second molar
this opens contacts between
the teeth.

film in center of palate

 top edge of PID above ring

Some patients, especially larger individuals, will have longer

than normal teeth. With the normal positioning of the film and
alignment of the beam, the apices of the teeth will be above
the edge of the film (not visible or “cut off”) as in the
illustration above left. To compensate for this, increase the
angle of the beam and raise the PID slightly (illustration
above right). You are purposely foreshortening the image.
 If a patient has Tori (maxillary or mandibular):
palatal torus Place film on the
opposite side of
palatal torus (away
from teeth being
radiographed); film
should not rest on
torus.

Place film between

torus and tongue,
making sure it
doesn’t rest on top
of torus.
mandibular torus
 Mandibular Incisor

film positioned away from

film centered on midline teeth, pushing tongue
back slightly
 Mandibular Canine

film positioned away from

film centered on canine teeth, pushing tongue
back slightly
 Mandibular Premolar

film equidistant from lingual

front edge of film anterior to
surface of teeth (red arrows);
middle of canine; approximately
film placed toward center of
centered on 2nd premolar
mouth, displacing tongue
 Mandibular Molar

centered on second molar film equidistant from lingual surface

of teeth; in this case the film will
usually contact lingual of molars
 Bisecting Angle
Technique

X-ray beam

X-ray beam perpendicular to bisecting line

Bisecting Angle Technique
Head Position

(head tipped back)

For the bisecting angle technique, the head

should be positioned as above, with the arch
being radiographed parallel to the floor, both
side-to-side and front-to-back.
The film (# 2 - adult, # 0 – small child) is positioned with
the long axis vertical and the dot-end of film extending
¼” beyond the incisal edge. With the all-white side of film
facing the teeth, the finger pressure is applied at the
cervical portion of the crown to avoid film bending.
The film (# 2 - adult, # 0 - child) is positioned with the
long axis horizontal and the dot-end of film extending ¼”
beyond the occlusal surface. With the all-white side of
film facing the teeth, the finger pressure is applied at the
cervical portion of the crown to avoid film bending.
 Bisecting Angle Film Placement

Film placement, as indicated above, is the same for maxilla

or mandible. The film is placed vertically for anterior teeth
(canine to canine) and horizontal for posterior teeth.
The film is held in the proper position using the
thumb (maxillary anteriors, above left), index
finger of opposite hand (all other areas, above
middle) or by using the Rinn BAI instrument
(above right).
 Horizontal Angulation

Just as with bitewings, the horizontal angulation should

be adjusted so that a line connecting the buccal
surfaces of the posterior teeth (dotted line above left) is
parallel with a line connecting the front and back edge of
the PID (dashed line above left). This results in the x-
rays being perpendicular to the line connecting the
buccal surfaces of the teeth, opening the contacts.
 film equidistant from lingual
surface of teeth (red arrows)

When using the Rinn bisecting angle

instrument, align the PID with the ring; this will
automatically open the contacts if the film is
positioned properly in the mouth (see above).
 Occlusal Film
Identify large lesions
Determine bucco-lingual location
View developing anterior dentition
Image patients with trismus (if
pan not available)
 Head Position
Maxillary occlusal: Maxilla parallel to floor
Mandibular occlusal: Mandible perpendicular
to floor

Film Position
Centered on area of interest
All-white side facing x-ray tube
Patient bites gently on film

Exposure Settings
Normal Maxillary = PA/ BW
Mandibular = PA/BW
True Maxillary = 4X PA/BW
X-ray Beam Position
Centered on area of interest
Vertical angulations (see below)
# 4 size film used in
adults for occlusal
films. In the film at
right, the location of
the impacted canine
is revealed.

# 2 size film used for

occlusal in children
to image anterior
developing dentition
(see film at left)
 Bitewing
Technique
 Bitewing Head Position

As mentioned previously, the head should be positioned

so that the maxillary arch is parallel to the floor, both
side-to-side and front-to-back, when using bitewing tabs.
The head needs to be supported by the headrest.
 Bitewing Film Placement

Front edge anterior to Film centered on second

middle of mandibular molar (if 3rd molars are
canine (approximately erupted; otherwise center
centered on 2nd on contact between 1st and
premolar) 2nd molar).
The stick-on bitewing tab is always centered top-to-
bottom with the film oriented horizontally (see picture
above). The tab is placed on the all-white side of the film.
When some teeth are missing, the tab may be placed
more anteriorly or posteriorly (see above right) to allow
maximum contact with the teeth that are present.
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. Always start with the
premolar bitewing, then proceed to the molar bitewing
on that same side. Make sure the patient’s head is
against the headrest before aligning the x-ray beam.
 10°

positioning guide

The vertical angulation is

always set at +10 degrees
(the tubehead is pointing
downward). Make sure the
patient’s head is
positioned properly before
attempting PID alignment.
 correct incorrect

The horizontal angulation is adjusted so that a line

connecting the front and back edge of the PID (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 (see next slide). Make sure they remain closed on
the tab. The front edge of the PID should be ¼” anterior to
the front edge of the film.
Patient opening lips (“smiling with teeth
together”) to allow visualization of
buccal surface of posterior teeth.
When using the Rinn BW instrument, the
film must be placed in the mouth so that incorrect
the film is equidistant from the teeth along
its entire length (see above). The two
placements shown on right are incorrect,
and will result in overlap.

For the premolar placement, the front edge

of the film should contact the lingual of the
incisors. For the molar placement, the film
should be approximately centered on the
2nd molar if 3rd molars are present. incorrect
When using the Rinn BW instrument, align the PID
with the ring. This automatically aligns the x-ray
beam with the correct vertical and horizontal
angulation (assuming the film was positioned
properly in the mouth). The x-ray beam will be
perpendicular to the film when using the BW
instrument.
 Premolar Bitewing

On a premolar bitewing, the contact between

the canine and 1st premolar should be clearly
visible.
 Molar Bitewing

Molar periapical films should always be centered on the

2nd molar. Molar bitewings, however, should only be
centered on the 2nd molar if third molars are erupted into
the mouth. If no 3rd molars are erupted, center the film at
the contact between the 1st and 2nd molar. In film above,
the film was too posterior, showing the posterior
edentulous area which would be better visualized on
periapicals or panoramic film.
Vertical Bitewings

Vertical bitewings, with

the long axis of the film
vertical, are used when
there is extensive bone
loss due to periodontal
involvement. They can be
used both anteriorly (2
for canines, 1 for
incisors) or posteriorly
(premolar and molar on
each side).
Cotton rolls can be used to help support the tab or
bitewing instrument in edentulous areas. As mentioned
previously, the tab can also be moved forward or
backward on the film to get better tooth support.
 Intraoral Technique Errors
Paralleling Technique: The most common
technique error with the paralleling technique is
poor film placement. The molar film (maxillary or
mandibular) not being far enough back is the most
common; the premolar film (maxillary or
mandibular) not being far enough forward ranks
next and the maxillary central-lateral film too
posterior is the third most common. The other
technique errors are infrequently seen.
 Intraoral Technique Errors
Bisecting Angle Technique: When using a finger
to hold the film in the mouth, errors are more
common because there is no ring to help in PID
placement. While incorrect film position is still the
most common error, cone-cutting, incorrect
horizontal angulation, film bending, elongation
and foreshortening are also frequently seen. While
fewer errors are seen when using the BA
instrument, usually the contraindications for
using paralleling also apply to using the BA
instrument. In general, more errors occur using
the bisecting angle technique than with any other
technique, including paralleling, bitewing and
panoramic.
 Intraoral Technique Errors

Bitewing Technique: When using the Rinn bitewing

instrument, film placement is the most common
error. Next in line would be overlapping. Most of
the other errors would not occur very often.

When using tabs, film placement is still the most

likely to occur, but cone-cutting and overlap will
also frequently be seen.
 Panoramic
Radiography
Prepare patient: Remove glasses, ear/tongue rings,
necklaces, appliances, hearing aids, bobbypins,
barets. Basically, anything removable between neck
and top of ears.

Load film (T-Mat,

Ektavision) between
screens (rare earth –
green light) and position
cassette in machine

With gloves on, place

bitestick cover
Place lead
apron
 Panoramic Positioning
1. Incisors in notch of bitestick

2. Midsagittal plane
centered

3. Frankfort Plane
parallel to floor

4. Spinal column straight

(see next two slides)
 FP
MSP parallel to
centered floor

teeth in notch of bitestick

 Correct Incorrect

Patient standing upright Patient slouched

with spinal column
straight
Advise patient to swallow to feel tongue contact
palate. Tell patient to keep the tongue against
the palate the entire time of exposure (20
seconds).

Set correct exposure

factors. Depress
exposure button (red
arrow) and hold
down until the
machine completes
its rotation.
 Positioning Errors
Head tipped up - worst; lose apical info on
most or all of maxillary teeth.
Head tipped down - minimal loss of info
(mand. incisors only)
Head turned - hardest to avoid; may be
difficult to see if patient is centered
Teeth in front of notch or behind notch –
should not happen; easy to confirm teeth
are in notch
 Comparison of Techniques
Comfort: The panoramic technique is the most
comfortable for the patient, followed by occlusal, bitewing,
bisecting angle and paralleling; paralleling is the most
uncomfortable.

Distortion: The occlusal technique produces the most

distortion, followed closely by the bisecting angle technique.
Paralleling, bitewing, and panoramic techniques produce
roughly equal amounts of distortion, which is much less than
occlusal and bisecting techniques.

Magnification: The panoramic film produces by far the most

magnification, in the 20-30% range. Occlusal technique is
next, followed by paralleling, bisecting and bitewing
techniques. The bitewing technique results in the least
magnification, whether using tabs or the Rinn bitewing
instrument.
This concludes the review of paralleling, bisecting
angle, occlusal, bitewing and paralleling techniques.
You should also review the technique errors on the
radiology website:

http://www.dent.ohio-state.edu/radiology/pan-tech-err.ppt
http://www.dent.ohio-state.edu/radiology/intraoral-tech-err.ppt

If you have any questions, e-mail me at

jaynes.1@osu.edu or call 688-3374.