X-RAY TECHNIQUES AND

INTERPRETATIONS

T.HUDSON JONATHAN
CONTENTS
 Introdution
 Radiographic techniques
-paralleling technique
-bisecting angle technique
 Bitewing radiography
 Occlusal radiography
 Panaromic radiography
 CBCT(Cone Beam Computed Tomography)
 Magnetic resonance imaging
 Subtraction radiography
 Xeroradiography
 Digital radiography
 Radiographic assessment of periodontal condition
 Normal radiographic features of healthy alveolar bone
CONTENTS
 Radiographic appearance of periodontal diseases
-horizontal bone loss
-vertical bone loss
-furcation involvement
 Chronic periodontitis

 Aggressive periodontitisa

 Periodontal abcess

 Nectrotizing ulcerative periodontitis

 Systemic disease affecting periodontium

 Limitations of radiographs in periodontal condition

 Conclusion

 Reference
Introduction
 X-ray is an electromagnetic wave of high energy and very
short wave length,which is able to pass through many
materials that are opaque to light.

 X-ray was discovered in 1895 by Wihelm conrad roentgen

(1845-1923) who was a professor at wuzerberg university in
germany.

 Working with a cathode ray tube in his laboratory,he observed

a fluorescent glow of crystals on a table near his tube.
 The tube that roentgen was working with consisted of a
glass envelope(bulb) with positive and negative electrodes
encapsulated in it.

 The air in the tube was evacuated and when a high voltage
was applied,it produced a fluorescent glow.

 Roentgen shielded the tube with heavy black paper and

discovered a green colored fluorescent light generated by a
material located a few feet away from the tube.

 Roentgen also discovered that the ray could pass through

the tissue of humans,but not bones and metal objects.
Radiographic techniques
Intra oral
- Paralleling technique
- Bisecting angle technique

Paralleling technique:
- Patient preparation:
 Prior to starting to take flims,the patient must be positioned

properly.Seat the patient and ask them to remove glasses and

any removable appliances.
 Place the lead apron and thyroid collar on the patient and

adjust the headrest to support the head while taking

flims.Raise or lower the chair to a comfortable height for the
operator.
Procedure
 The paralleling technique is accompained by placing the
receptor parallel to the long axis of the tooth.
 After this parallel relationship has been established,the

central ray must be directed perpendicular to both the

tooth and the receptor.
 Because the receptor cannot always be placed as close as

possible to the tooth due to flim holding device,image

magnification may occur.
 It is said to be superior when performed correctly as it

produce an image of linear and dimensional accuracy.To

facilitate flim placement ,the flim may be tipped up to 20
degrees.
Paralleling technique
Advantages
 It has better dimensional accuracy as it results in less
distortion.
 The alingment of x-ray beam is simplified.
 Due to positioning instrument,it is easier to standardize

flims.
 Beacuse of paralleling instrument it is easy to align the x-

ray beam irrespective of head position.

Disadvantages
 Less comfortable as the flim impinges on palate or floor of
the mouth.
 More limited due to the anatomy of the palate or floor of

mouth.
 Positioning the holder within the mouth can be difficult for

inexperienced operators.
 The apices of the teeth can sometimes appear very near

to the edge of the flim.

Bisecting angle technique
 It is an alternative to paralleling technique for taking
periapical flims.The paralleling technique is recommended
for routine periapical radiography,but there are some
instances where it is very difficult to patient anatomy or
lack of co-operation.
 In this situation the bisecting angle technique is used.The

flim can be held in the mouth with the thumb or index

finger or a bisecting instrument may be used.
 In this technique x-ray beam is directed perpendicular to an

imaginary line which bisects the angle formed by the long

axis of the tooth and flim.
Bisecting angle technique
Advantages
 Because of the flim placed at angle to long axis of the
teeth,the flim doesn’t impinge on tissue as much,so it is
more comfortable.
 Flim holder is not needed ,as patient can hold the flim

using a finger.
 The flim can be angled to accomodate different anatomic

situation using this technique.

Disadvantages
 Because the flim and teeth are angled to each other more
distortion will occur.
 Patient acceptance of bisecting instrument is not much

better than paralleling due to stress of finger retention.

 As there is basically no use of flim holder,it is difficult to

visualize where x-ray beam should be directed.

 Flim is less stable as the retention is done using

finger,which may cause chances of moving.

Bitewing Radiography
 Bitewing radiography is used to detect interproximal
caries and alveolar bone levels.
 The receptor is placed in the mouth parallel to the crowns

of the maxillary and mandibular posterior teeth.

 The flim is stabilized as patient is asked to bite the tab or

bitewing holder.
 The horizontal angle of the x-ray beam is then directed

through the contacts of the posterior teeth at 5-10 degree.

 Receptors may be positioned in horizontal or vertical
dimension with this technique,depending on the area to
be examined.

 Bitewing may be taken in anterior segment as well.In

periodontics it is prescribed to be of 4 vertical bitewing
receptors posteriorly and 3 vertical bitewing receptors
anteriorly.

 So it allows to evaluate both bone level and caries

detection.
Bitewing radiography
Occlusal radiography
 Occlusal radiography is used to examine a large areas of
upper and lower jaw.The palate and floor of the mouth
may also be examined.
 It is generally taken as a supplementary radiography

along with periapical and bitewing radiograph.

 The flims are bigger than IOPA as it has to cover the

complete upper or lower jaw.It is of length 57mm and

breadth 76mm.
Technique
 The patient positioning is done prior to flim
placement.Patient is seated such that the sagittal plane is
perpendicular to floor and occlusal plane parallel to floor.
 The apron must be properly placed to avoid interference

with the radiographic exposure.

 use a type 4 receptor with tube side of receptor toward

the maxilla,the receptor is placed crosswise in the mouth

like a cracker.
 The central ray is directed at an angle of +65 degree and

a horizontal angulation of 0 degree.

 In maxilla it is used to view alveolar fractures, cyst,
supernumerary teeth,impacted canines.
 In the mandible the image field includes buccal cortical

plate,lingual cortical plate and teeth from 37-47.

 Projection of central ray is at the midline through the floor

of mouth.It is approximately 3cm below the chin at 90

degree to the receptor.
 The patient is placed tilted,that the occlusal plane is 45°

above horizontal plane.Type 4 receptor is used with the

tube of the receptor towards mandible.
Occlusal radiography
Indications
 Salivary stones in the duct of submandibular gland.
 To evaluate the extent of lesions.
 Boundaries of maxillary sinus.
 Fracture of maxilla and mandible.
 Foreign bodies in maxilla and mandible.
 To examine cleft palate.
 Retained roots,supernumerary teeth,unerupted or
impacted.
Panaromic radiography
 Panaromic radiography or pantomography is a extra oral
radiographic technique for producing a single tomographic
image of the facial structures.
 It includes both maxillary and mandibular dental arches

and their supporting structures in a single large flim.

 It is a curvilinear variant of conventional tomography,and

is based on the principle of reciprocal movement of an x-

ray source and an image receptor around a central point
or plane called the image layer in which the object of
interest is located.
Patient positioning:
 Remove all removable appliance,metallic objects,
necklace, ear rings.Tongue and lip rings should also be
removed if at all possible.
 Explain the procedure to the patient and make him/her to

wear a lead apron without thyroid collar.

 The purpose of lead apron is to reduce the somatic

exposure of radiosensitive tissues and minimize genetic

exposure to the reproductive organs.
 The most radiosensitive regions of head and neck are

thyroid and salivary glands.

Procedure
 The mid sagittal plane is positioned perpendicular to right
angle to floor and centered right to left.
 The plane of occlusion is positioned parallel to the

floor.The frankfort plane,tragal-canthus plane and ala-

tragus are used to align the vertical position of the head.
 Anteroposterior plane is aligned with specific landmark

that varies among panaromic machines.It is aligned

between maxillary lateral and canine contact.
 It is a technique of producing tomographic image by
sectioning of the parts and simultaneous movement of x-
ray tube head and flim cassette in opposite direction to
produce the depth of the tissue.
 In the image the anterior part appears narrower than the

posterior,so some patients seems to not match with it.

 Correct patient positioning is essential for optimal
results.Image distortion occurs,when structures are
anteriorly positioned which causes narrowing and when
posteriorly positioned causes widening of image.
Panaromic radiography
Indications
 For initial examination of new patients in all age groups
that can provide required insight or idea in determining
the need for other projections and general screening.
 In TMJ disturbances caused by malocclusion.
 In patients suffering from pain of unknown origin.
 In patients who are unable to open the mouth,with limited

mouth opening,cannot tolerate intraoral radiography or

patients suffering from severe gagging.
 To eliminate the presence of any underlying disease
before complete or partial dentures are constructed.
 Suspected bony swelling or known large lesions and in

cases of mandibular asymmetry.

 In patients with history of trauma to confirm or rule out

the possibility of fractures,especially mandible.

 Before and after surgical intervention of lesions.
CBCT(Cone Beam Computed Tomography)
 It is the most significant technological advancement in
maxillofacial imaging.It is a form of x-ray computed
tomography in which x-rays are divergent forming a cone.
 In this the 3D visualization of manifested disease or

deformation gives diagnostic accuracy,which enables

better understanding for planning of treatment.
 There are some technological factors that made it possible

-The development of compact high quality flat panel

detector arrays.
-Reduction in the cost of computers capable of
reconstruction
-Development of inexpensive x-ray tube capable of
continuous exposure.
-Limited volume scanning.
 Specific application in dentistry CBCT technology has a

substantial impact on maxillofacial imaging.

 It is not a replacement of panaromic or other radiographs

but it should be considered as a complimentary for

specific application.
Patient selection:
 There should be justification of the exposure to the

patient, so that the total diagnostic benefits are greater

than the individual determining the radiation may cause.
 Should be used only when a periapical or panaromic

cannot provide necessary information for patient

diagnosis and treatment planning.
 Cone beam computed tomography,should not be repeated

routinely on a patient without a new risk/benefit

assessment.
CBCT(Cone Beam Computed
Tomography)
Implant assessment
 The more important of CBCT is of planning of dental
implant placement which gives clear detail of that region.
 Ability to visualize the site of implant in the
mesiodistal,faciolingual and superio-inferior dimensions.
 It has ability to allow reliable,accurate measurements.
 Capacity to evaluate trabecular bone dentisty and cortical

thickness.
 Ability to determine axial orientation of the implant
 Gives cross sectional image of alveolar bone height,

width,angulation and accuracy depicts vital structures

such as IAN canal,sinus in maxilla.
Advantages
 Image accuracy
 Rapid scanning time
 Multiplanar reformating
 Better images with good spatial resolution
 Economical,comfortable and safe
 Soft tissue assessment
 Assessing bone density
Magnetic Resonance Imaging
 Magnetic resonance imaging was described by paul
lauterbur in 1973 and peter mansfield further developed
use of the magnetic field and developed for clinical use
around 1980.
 To make a magnetic resonance image ,the patient is

placed inside a large magnet.This magnetic field causes

the nuclei of many atoms in the body,particularly
hydrogen to align with the magnetic field.
 The scanner then directs a radiofrequency pulse into the

patient,causing some hydrogen nuclei to absorb energy.

 When the RF pulse is turned off,the stored enery is
released from the body and detected as a signal in a coil
in the scanner.
 This signal is used to construct the magnetic resonance

image,in essence a map of the distribution of hydrogen.

 It has an advantage of being non-invasive using non-

ionizing radiation and making high quality images of soft

tissues resolution in any imaging plane.
 Because of its excellent soft tissue contrast resolution,MRI
is useful for instance, the position and integrity of the disk
in the condyle, for soft tissue disease especially neoplasia
involving soft tissue such as tongue,cheek,salivary glands
and neck determining malignant involvement of lymp
nodes and determing perineural invasion of malignant
neoplasia.

 Disadvantage include its high cost,long scan times and

the fact that the various metals in the imaging field either
will distort the image or may move in the strong magnetic
field injuring the patient.
Magnetic Resonance Imaging
 Xeroradiography
 It is a method of imaging which uses the xeroradiographic
coping process to record images produced by diagnostic
x-rays.

 It is a method of x-ray imaging in which a visible

electrostatic pattern is produced on the surface of a
photoconductor.

 The xeroradiographic plate is made up of a 9 ½ to 14

inche sheet of aluminium,a thin layer of vitreous or
amorphous selenium photoconductor,an interface
layer,and an over cutting on the thin selenium layer.
 The XR plate is charged to high positive potential by
corotron.It is then placed in a cassette and used in a
manner similar to that with conventional flim in its
cassette.

 A positive XR refers to image that is blue and white with

blue representing dense areas.

 A negative XR refers to image that is blue and white but

that has been reversed so that represents the dense
areas.
Application:
 The radiography has found application in soft tissue

imaging:in radiographic examination of the mammary

glands,muscles,tendons and ligaments.

 The main advantage of xeroradiography include enhanced

visualisation of the borders between images of different
densities(edge effect),low contrast which enables
differentiation between fat,muscle and bones.
 Digital Radiography
 Digital imaging is an method of imaging that creates an
image that can be viewed or stored on a computer.

 Digital imaging incorporates computer technology in the

capture,display,enhancement,and storage of direct
radiographic images.

 Digital image offers some distinct advantages over

film,but like any emerging technology,it presents new and
different challenges for the practioner to overcome.
Advantages:
 All the procedures can be visualised almost immediately.
 Any area of the picture can be enlarged .
 Provides necessary magnification.
 Good resolution.
 Conventional developing is not necessary.
 Bone pattern,its height and depth during implant
placement can be visualised.
Subtraction radiography
 Most assessment of progressive alveolar bone loss in
clinical practice today is achieved by interpretation ie
visual comparision of radiographs taken over time.
 Unfortunately it is difficult to detect small changes that

occur between examinations using interpretation because

the radiograph contains a superimposed background of
the teeth,cortical bone and trabecular bone.
 Digital subtraction radiography was introduced to
dentistry in 1980’s.This technique is used to detect small
changes in hard tissue that occur between examinations.
 In brief,digital subtraction radiography uses specialized
computer program to remove all structures that have not
changed from a set of two x-ray flims taken at different
examinations.
 This image processing procedure subtracts unchanging

teeth,cortical bone and trabecular pattern leaving only the

bone gain or loss standing out against a neutral grey
background on the subtraction image.
 The area of change may be superimposed on the original

radiograph to improve the ability of the clinician to

interpret the subtraction image.
 Additional software can determine the size,mass or
density of the region of change.These technique have
been shown to be more than 90./.sensitive and specific in
determining small bony changes.
 More recently this quantitative method has been shown to

co-relate highly with technique used to measure bone

mass in medicine.
Subtraction radiography
Pre-operative Post-operative
Radiographic assessment of periodontal
conditions
 Radiographs are especially helpful in the evaluation of the
following features.
 Amount of bone present.
 Condition of alveolar crest.
 Bone loss in the furcation area.
 Width of periodontal ligament space.
 Local irritating factors that increase the risk of periodontal

disease.
-calculus
-poorly contoured or over extended restoration
 Root length and morphology and the crown to root ratio.
 Open interproximal contacts which may be sites for food

impaction.
 Anatomic considerations.

-Position of maxillary sinus in relation to periodontal

deformity.
-Missing,supernumerary,Impacted and tipped.
 Pathologic considerations.

-Caries,periapical lesion,root resorption.

Normal radiographic features of healthy
alveolar bone
 Presence of thin evenly pointed margins in the interdental
crestal bone in the anterior region.Anteriorly ,cortication at
the top of the crest may not always be evident due to the
small amount of bone present between the teeth.
 Presence of thin,smooth,evenly corticated margins in the
interdental crestal bone in the posterior region.
 Interdental crestal bone is continuous with the lamina dura
of the adjacent teeth,and the junction of the two forms a
sharp angle.
 Loss of clarity or unsharpness of this angle may be an
indication of periodontal involement.
 Thin even width of periodontal ligament space.
Radiographic appearance of periodontal diseases
 The direction of the bone loss or bone destruction is
determined using the CEJ as the plane of reference.The
bone destruction can be in the form of
 Horizontal bone loss:when the bone loss occurs on a plane

that is parallel to a line drawn from the CEJ of a tooth to

that of an adjacent tooth,it is called horizontal bone loss.
 Vertical bone loss:when there is greater degree of bone

loss on the proximal aspect of one tooth than on the

adjacent tooth,the bone level is angular or not parallel to
a line joining CEJ.This type of bone loss is said to be
vertical or angular bone loss.
Furcation involvement:
 Extension of periodontal pocket
between the roots of multi-rooted tooth
is called furcation involvement.

 Radiographs can be helpful in locating

furcation involvement, however the
furcation involvement cannot be seen
unless the bone resorption extends
apically beyond furcation.
Chronic periodontitis
 It shows loss of corticated interdental
crestal margin,the bone edges become
irregular are blunted.
 Widening of PDL space at the crestal

margin.
 Loss of normally sharp angle between

crestal bone and lamina dura.

 Localised or generalised bone loss of

alveolar bone.
 Loss of bone in furcation area of multi

rooted tooth.
Aggressive periodontitis

 In first molar region,radiographs shows

localised deep pockets and vertical bone
resorption that often is bilateral and
symmetric.
 An arch shaped loss of alveolar bone extending
from distal surface of second pre molar to the
mesial surface of second molar is also
seen.Similar involvement is apparently around
the anterior teeth.
 There is usually a distolabial migration of the
maxillary incisors with diastema formation.
 Clinically the patients are healthy except for
periodontal disease and there is no association
with any systemic disease.
Periodontal abscess

 A periodontal abscess often arises in a pre-existing periodontal

lesion which is usually precipitated by alteration in the
subgingival flora,host resistance or both.
 This is an acute exacerbation of a process occuring in a chronic
periodontal pocket ,which may result from partial or complete
occlusion of the orifice of the pocket,furcation involvement or
diabetes.
 Radiographically,underlying bone changes may be
indistinguishable from other forms of periodontal bone
destruction.
 In an acute periodontal abscess there is no visible radiographic
findings,and this is diagnosed clinically where the signs of
acute inflammation and infection are evident.
 Occurrence of an abscess in the buccal and
lingual aspect shows a crater like
radiolucency,which will make the root
clearer in the affected area.
 In lateral periodontal abscess,it appears as

a localised area of increased radiolucency

with poorly defined margins.
 In the apical variety usually as a sequela of

vertical bone loss,it appears as an area of

increased radiolucency with hazy borders.
Necrotizing ulcerative Periodontitis
 Necrotizing ulcerative periodontitis is similar to that of
necrotizing ulcerative gingivitis,but it also shows loss of
clinical attachment and alveolar bone.
 This destructive form of periodontitis may arise within the

zone of pre-existing periodontitis or it may present a

sequelae of single or multiple episodes of necrotizing
ulcerative gingivitis.
 Patients affected are often younger than most patients

affected with chronic periodontitis and often show

immunosuppression and malnutrition.
Systemic Disease affecting
periodontium
 Systemic disease like
hyperthyroidism,scleroderma,diabetes mellitus and
esinophilic granules may show,refraction of bone and
absence of lamina dura,which can mimic the appearance
of periodontal disease.
 In scleroderma there is generalised widening of the

periodontal ligament space.

 patient who are HIV positive and immunocompromised

can present with distinct form of necrotizing gingivitis and

periodontitis.
 Radiography provides no direct evidence of the soft tissue
involvement in gingivitis.
 However in severe cases of acute ulcerative
gingivitis,where there have been extensive craters of the
interdental papilla,inflammatory destruction of underlying
crestal bone may be observed.
Limitations of radiograph in periodontal condition

 Radiograph provides a restricted two dimensional

representation of the three dimensional anatomic structures.
 The changes that occur in the soft tissue cannot be
preceived.They do not provide information about the health
of soft tissues,presence of mucogingival defects or the
position of the gingival marigin.
 The very earliest sign of periodontal disease cannot be
detected radiographically,however this is possible by clinical
examination.
 It is difficult to recognize any existing bony defects that are
overlapped by existing bony walls on the resultant
radiograph.
Conclusion
 Periodontium can be considered healthy,when periodontal
tissue exhibits no evidence of disease.
 Unfortunately this cannot be ascertained from radiographs

alone.Dental radiographs must be used in conjugation

with clinical examination to establish the existing
condition.
 Clinical examination provides information about the soft

tissue and radiographs permit evaluation of the hard

tissues.
References
1. Text book of oral radiology-white and paroah.
2. Carranza clinical periodontology-12th edition.
3. Oral and maxillofacial radiology-kamal G pillai.
4. Fundamental of periodontics-2nd edition Thomas
G,Wilson,Kenneth S.Kornman.
5. Periodontics revisited-Shalu Bathla.
6. Periodontology 2000 vol-73, 2017.
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