Dental

Radiographic
Techniques
and
Safeguards
for the Dental
Assistant
• Chapter 42
• Extra oral Imaging

• Modern Dental Assisting Edition 13 Doni L Bird,

Debbie S, Robinson
• Copyright 2021 by Elsevier, Inc. All rights reserved
 Extraoral Imaging

Chapter 42
 Modern Dental Assisting Edition 13 Doni L Bird, Debbie S, Robinson
 Copyright 2021 by Elsevier, Inc. All rights reserved
Learning Objectives
Lesson 42.1: Extroral Imaging
(Slide 1 of 2)

• Pronounce, define, and spell the key terms.

• Discuss panoramic imaging, which includes:
• The purpose and uses of panoramic imaging.
• The equipment used in panoramic imaging.
• Steps for patient preparation and positioning in panoramic imaging.
• The errors that may occur during patient preparation and positioning
during panoramic imaging.
Learning Objectives
Lesson 42.1: Extroral Imaging
(Slide 2 of 2)

• Discuss three-dimensional imaging, which includes:

• The difference between a computed tomography (CT) scan and cone
beam computed tomography (CBCT).
• The uses of three-dimensional imaging.
• The advantages and disadvantages of CBCT.
• Identify the specific purpose of each type of the extraoral film projections.
 • Extraoral images (outside the mouth) are taken
when large areas of the skull or jaw must be
examined or when patients are unable to open
their mouths for film placement
• Extraoral radiographs are useful in
evaluating large areas of the skull and jaws
but are not recommended for detection of
Introduction subtle changes, like caries or early
periodontal changes
• Introduction of full-featured digital panoramic
units and a new technology called cone beam
computed tomography (CBCT)
• Almost all digital extraoral images have
better resolution than film-based images
Panoramic Imaging
(Slide 1 of 2)

• Panoramic imaging allows the dentist to view the entire dentition and related
structures on a single image
• Used to locate impacted teeth, detect jaw lesions, observe eruption patterns
• In the past, panoramic images were not recommended for diagnosing dental caries
or periodontal disease or lesions because of the overlapping of posterior contact
areas
• Bitewing images had to be used to supplement the panoramic images
 • This situation has changed with the introduction
of the new full-featured digital panoramic units
Panoramic with a special C-arm
• Panoramic digital images produced with these
Imaging machines can show small interproximal carious
lesions
(Slide 2 of 2) • They can “open up” contacts in the premolar
areas that traditional panoramic machines
showed as being overlapped
Types of Panoramic Units

• Two types of panoramic machines

• Film-based imaging
• Direct digital imaging
• The main difference between direct digital panoramic imaging and film-
based panoramic imaging is the image receptor
• Digital units use a sensor array rather than film, and the image is produced
immediately on the computer monitor rather than on film after processing
 Basic Concepts

• In panoramic imaging, both the film/sensor and the tubehead rotate around the patient
• Produces a series of individual images
• When these images are combined on a single film, an overall view of the maxilla and the
mandible is created
Focal Trough
(Slide 1 of 2)

• Focal trough is an imaginary three-dimensional curved zone in which

structures appear clear on a panoramic radiograph
• When a patient’s jaws are positioned within this zone, the resulting
radiograph is reasonably clear and well defined
• If jaws are positioned outside of this zone, images on the radiograph appear
blurred or indistinct
 Focal Trough
(Slide 2 of 2)
• The size and shape of the focal trough vary with the
manufacturer of the panoramic unit
• Panoramic x-ray units are designed to accommodate
the average jaw
• The quality of the resulting radiograph depends on
how the patient’s jaws are positioned within the
trough and how closely the patient’s jaws conform
to the focal trough
 Equipment

• Tubehead
• Head positioner
• Exposure controls
• Film and intensifying screens
 • Panoramic x-ray tubehead is similar to intraoral
tubehead
• Has a filament that produces electrons and a
target that produces radiographs
• Collimator used in the panoramic x-ray machine is
a lead plate with an opening shaped like a narrow
Tubehead vertical slit
• Different from the intraoral tubehead, the vertical
angulation of the panoramic tubehead is not
adjustable
• Tubehead of the panoramic unit rotates behind
patient’s head as film rotates in front of patient
 • Each panoramic unit includes a head
positioner used to align the patient’s
teeth as accurately as possible
• Each head positioner consists of a chin
Head rest, a notched bite-block, a forehead
rest, and lateral head supports or
Positioner guides
• Each panoramic unit is unique, and the
operator must follow the
manufacturer’s instructions to position
the patient correctly in the focal trough
Exposure Controls

• Allow the milliamperage and kilovoltage settings to be adjusted to

accommodate patients of different sizes
• The exposure time cannot be changed
 Film and Intensifying Screens

• Film-based panoramic imaging uses a type of extraoral screen film that is held in a film
cassette
• This type of film is sensitive to the light emitted from intensifying screens in the film-
holding cassette
 Common Errors
• To produce a diagnostic panoramic image and
minimize patient exposure, you must avoid mistakes
• You must be able to recognize the following
common patient preparation and positioning
errors and understand what you can do to
prevent such errors from occurring
 Patient Preparation Errors
(Slide 1 of 2)

• Ghost images
• If all metallic or radiodense objects are not removed before exposure, a “ghost” image
results
• A ghost image looks similar to the real object, except that it appears on the opposite
side of the film
• The ghost image will appear blurred and larger
• Solution: The patient must be instructed to remove all radiodense objects from the head
and neck region before being positioned
 Patient Preparation Errors
(Slide 2 of 2)

• Lead apron artifact

• If the lead apron is incorrectly placed or if a lead apron with a thyroid collar is used
during exposure of panoramic films, a radiopaque cone-shaped artifact results
• Interferes with the diagnostic information
• Solution: Use a lead apron without a thyroid collar, and place the lead apron low around
the neck of the patient so that it does not block the x-ray beam
Patient Positioning Errors:
Lips and Tongue

• The patient’s lips must be closed on the bite-block during exposure of a panoramic film.
• If they are not, the result is a dark radiolucent shadow that obscures the anterior teeth
• Also, the tongue must be in contact with the palate during exposure of a panoramic film
• If it is not, the result is a dark radiolucent shadow that obscures the apices of the
maxillary teeth
• Solution: Close the lips around the bite-block, swallow, and then raise the tongue up to the
palate
Patient Positioning
Errors:
Chin Too High
• Also referred to as positioning of the Frankfort plane
• If the Frankfort plane is incorrect and the patient’s chin
is positioned too high or is tipped upward:
• Hard palate and the floor of nasal cavity will
appear superimposed over the roots of the
maxillary teeth
• Detail in the maxillary incisor region will be lost
• Maxillary incisors will appear blurred and
magnified
• A “reverse smile line” will be apparent on the
radiograph
• Solution: Position the patient so the Frankfort plane is
parallel to the floor
 • If the Frankfort plane is incorrect and
the patient’s chin is positioned too low
or is tipped downward:
Patient • The mandibular incisors will appear
blurred
Positioning • Detail in the anterior apical regions
will be lost
Errors: • The condyles will not be visible
Chin Too Low • An “exaggerated smile line” will be
apparent on the radiograph
• Solution: Position the patient so the
Frankfort plane is parallel to the floor
Patient • If the patient’s anterior teeth are positioned too
Positioning far back on the bite-block or posterior to the focal
trough, the anterior teeth appear “fat” and out of
Errors: focus on the radiograph
• Solution: Position the patient so that the anterior
Posterior to teeth are placed in an end-to-end position in the
Focal Trough groove on the bite-block
Patient Positioning Errors:
• IfAnterior toare notFocal
the patient’s anterior teeth Trough
positioned in the groove on the bite-
block and are too far forward or anterior to the focal trough, the teeth
appear “skinny” and out of focus
• Solution: Position the patient so that the anterior teeth are placed in an
end-to-end position in the groove on the bite-block
Patient Positioning Errors:
Spine Not Straight
• If the patient is not standing or sitting with a straight spine, the cervical
spine appears as a radiopacity in the center of the film and obscures
diagnostic information
• Solution: The patient must be instructed to stand or sit “as tall as possible”
with a straight back
 Cone Beam Computed
Tomography (CBCT)
• During a cone beam CT examination, the arm rotates around the patient’s
head in a complete 360-degree rotation
• While doing this, it takes anywhere from 200 to 600 two-dimensional (2D)
images that the software collects
• It then digitally combines them to form a 3D image that can provide the
dentist or oral surgeon with valuable information
 Advantages of CBCT

• This technology provides 3D views of the mouth, face, and jaw from any direction
• Manufacturers can provide software programs that will make it possible to clearly see all
anatomical structures, including soft tissue
• Some programs will even overlay the patient’s facial image onto the radiographic image
• The digital images can be easily adjusted, manipulated, and colorized on the computer
• Because the images are digitized, they can be easily sent over the Internet, allowing for
collaboration and consultation on cases
 Additional Advantages

• Even digital 2-dimensional images cannot provide any information about width
or depth, nor can they distinguish between the types of hard and soft tissues
• CBCT has greatly enhanced the diagnostic abilities of the dentist by providing
vital information necessary for:
• The proper placement of implants
• The extraction of impacted teeth
• Determining the exact location of the mandibular nerve prior to surgery
 Common Uses of CBCT

• More dentists, and especially dental specialists, are investing in CBCT units
for their offices
• Time for training is necessary to learn to use the CBCT hardware
• Additional training is required to interpret the data because they are
presented in a 3D view or as tomographic slices
Specialized • Extraoral images may be obtained using film-
based or digital systems
Extraoral • Extraoral radiographs provide images of larger

Imaging areas such as the skull and jaws

 • Extraoral radiographs may be taken with the
Specialized use of a standard intraoral x-ray machine
• Special head positioning and beam
alignment devices can be added to the
Extraoral standard x-ray unit to aid patient
positioning
Imaging: • Panoramic x-ray units may also be fitted with a
special device known as a cephalostat
Equipment • The cephalostat includes a film holder and
head positioner that allow the operator to
easily position the patient
Film and • Most extraoral exposures use screen
film placed in a cassette that has an
Intensifying intensifying screen
• An occlusal film (size #4) may be used
Screens for some extraoral radiographs, such as
lateral jaw or transcranial projection
• An occlusal film is a nonscreen film that
does not require a cassette; however, it
requires more radiation than is needed
with screen film
 • A grid is a device that is used to decrease
the amount of scatter radiation that reaches
The Grid an extraoral film during exposure
• Scatter radiation causes film fog and
reduces film contrast
(Slide 1 of 2) • A grid is composed of a series of thin lead
strips embedded in plastic that permits
passage of the x-ray beam
• The grid is placed between the patient’s
head and the film
The Grid
(Slide 2 of 2)

• When certain x-rays interact with the patient’s tissues,

scatter radiation is produced, which is directed at the grid
and film at an angle
• As a result, scatter radiation is absorbed by the lead strips
and does not reach the surface of the film to cause film fog
• Increased exposure time must be used to compensate for
the lead strips found in the grid
Procedures

• Step-by-step procedures for the exposure of an extraoral film involve

the same equipment preparation, patient preparation, and patient
positioning as for panoramic radiographs
• Before an extraoral film is exposed, infection control procedures must
be completed
• If an extraoral x-ray unit with a cephalostat is used, the ear rods must be
wiped with a disinfectant between patients
• Used most often in oral surgery and orthodontics
• Although some skull films can be exposed with a standard intraoral radiograph
machine, most require the use of an extraoral unit and cephalostat

Skull Radiography
(Slide 1 of 2)
• Skull radiographs may be difficult to interpret because of the numerous anatomic
structures that exist in the area
• Often, these structures appear superimposed over one another
• The most common skull radiographs used in dentistry include:
• Lateral cephalometric projection
• Posteroanterior projection
• Temporomandibular joint projection

Skull Radiography
(Slide 2 of 2)
Lateral Cephalometric Projection

• Used to evaluate facial growth and development, trauma,

disease, and developmental abnormalities
• This projection shows the bones of the face and skull as
well as the soft tissue profile
Posteroanterior Projection

• Used to evaluate facial growth and development, trauma,

disease, and developmental abnormalities
• This projection shows the frontal and ethmoid sinuses, the
orbits, and the nasal cavities
Temporomandibular
Joint (TMJ) Radiography

• Radiographs of the TMJ can be very difficult to examine because of the multiple adjacent
bony structures
• The articular disc and other soft tissues of the TMJ cannot be examined radiographically
• Special imaging techniques (e.g., arthrography, magnetic resonance imaging) must be used
• Radiographic projections of the TMJ can be used to show the bone and the relationship of
the jaw joint
Questions?