Transcribed by Eunsol Lee 7/29/2014

Radiology Lecture - Intraoral Technique: The Paralleling Method; Accessory Radiographic Techniques:
Bisecting Technique & Occlusal Projections by Professor Stabulas
Slide 1: Intraoral Radiographic Techniques
[Dr. Stabulas] Its still morning. So, good morning. So today, were going to talk about intraoral
radiographic techniques and a couple of different types of intraoral radiographic techniques. This is a 50
minute lecture, so dont panic if I dont finish this lecture because Im back on Thursday. For the digital
presentation, but whatever I dont finish today, Ill just carry over, if I dont finish. And if there is room
for discussion, well have it because its important that you understand this information. So, the
information that youre going to get basically now the second half of this course is information that
youre going to apply to the clinical setting. So, its more of a hands on segment. Where youll learn how
to take various different types of radiographs intraoal and extraoral. Also advanced technology like
digital, MRIs, CT, or CBCT, cone-beam technologies. And also, how to interpret films. How to look for
cries, periodontal disease. You know, every, the more common pathologies because youll have class in
third year that goes through, basically its radiology and pathology combines. So they go into a lot more
detail as far as pathologies are concerned. So this is more of a hands on clinical application part of the
term. Ok? So were going to start by talking about intraoral radiography.

Slide 2: INTRAORAL RADIOGRAPHY: THE PARALLELING METHOD
So intraoral radiography means that the receptor of which could be film or sensor, it could be film in a
film packet or it could be a film in cassette or it could be digital and both extraoral and intraoral
radiography uses digital radiography. So digital is just computerizing instead of using a film. So in any of
the cases where you, you are taking intraoral radiography, the receptor will be inside the mouth.
Whether it be film or sensor. The source of radiation will be outside the mouth, ok? So, the two most
common types of intraoral film that well be talking about that composes what we consider a series or
full mouth series of radiographs are periapical and bitewing radiographs. So the definition of periapical
film is the film that shows entire tooth from the incisor or occlusal surface, thats the difference
between anterior to posterior, to the apex and 3-4mm depending on where you read it. It could be 2-3
or 3-4mm of surrounding bone. The more you get of the surrounding area, the better youll be without
cutting out the incisal or occlusal surface of course. So, thats a periapical radiograph. The bitewing
radiograph will show both arches. In occlusion but not for occlusion purposes. Its more to look at the
interproximal regions. Because whether you use bisecting or paralleling, bisecting, bitewing films I
should say are always paralleling films because youre always getting a 90 degree angle. Ok. I dont know
I think you talked about patient protection, so you talked about selection criteria and choosing films. We
no longer take films because an insurance company says we can. After 6 months or 3 years for a full
mouth series. We prescribe radiographs as if we are prescribing medication. So the two things we take
into consideration is, the patients radiation history: When was your last x-rays taken, how may were
taken, what kind were they? Because theres a different, difference between a CT and a PA. Thats um
the abbreviation for periapical film or a bitewing. So you want to know that about the patient. You also
want to know patients risk factor for dental disease. So in terms of, basically you can find that out in
two ways. Look inside the patients mouth. And if you see a lot of restoration or not so may restorations.
Thats going to tell you about the patients susceptibility to caries right? Or if you see periodontal
disease or the lack of periodontal disease. So you want to know patients risk factors are because the
more risk factors there are, the more often you may want to take the films because you have to keep a,
you have to keep a watch on the patient and how the patient is progressing. Ok? So, when we do take a
full mouth series, not only in this facility, but in most places outside of this facility. Even on the board
exam when you see a full mouth series presented.

Slide 3: FULL-MOUTH SURVEY
It usually consists of 18 films and those 18 films canonists of maxillary periapicals, mandibular
periapicals, and bitewing films. Generally, there are 14 Periapicals taken, 8 of which are posterior so
theres 2 in each quadrant. 2 times 4 is 8, simple math. And there are usually, I always do that, I think I
move the arrow too quickly. There are usually 6 anterior periapical films taken. The bitewings in
generally use are usually horizontal. And theyre taken on premolar and molar regions. There are also
bitewings known as vertical bitewings. And generally used when you want a more vertical dimension. So
a perfection example of that would be if its a perio patient with more than 5mm of bone loss. If that
patient is more than 5mm bone loss, you need to see both arches and youre not going to see that on a
horizontal bite wing. So this is what constitutes a full mouth survey. FMS can be the abbreviation of full
mouth survey or you can, it could mean full mouth series. In some cases, they use FMX. Which would
mean full mouth X-rays. The problem with calling, calling a processed radiograph of an X-ray is that the
X-ray is really what comes out of the machine and not what youre looking at, but we all do it. As long as
we have the understanding that when we call it an X-ray, its actually a film based radiograph or a digital
image. Ok? And not an X-ray, but we still call it an x-ray when we look at it at the digital screen as well as
on the monitor. So these are periapical radiographs. Once again they show from incisor to apical and the
surrounding bone. If its in the anterior, its incisor. If its in the posterior, occlusal to apical.

Slide 4: PERIAPICAL RADIOGRAPHS
And if you take a periapical radiograph that doesnt meet the definition of what that should be, that may
constitute a retake. Ok. So lets say you took a periapical radiograph whether it was anterior or posterior
and it didnt show incisor or occlusal surface. Well, it may constitute a retake. Or if it didnt show 2-
3mm of bone around the apex, well then it would constitute a retake. Ok?

Slide 5: Bitewing radiographs
Bitewing radiograph and this is actually, we talked about number 3 sized film. This is number 3 sized film
which is preformed bitewings. And you can encompass both premolar and molar region all in one film.
You can also take a vertical bitewing which will look like this. This is all bitewing tabs that are being used
to hold the bitewing or you can use number 2 sized film, and hold it in vertical or horizontal direction.
But the bitewing is generally used to look at the interproximal regions. So anybody want to take a guess
of what you see here? Can you see that well enough? So thats an area that should be radiopaque which
is a darkish area on a film, but it should be radiopaque which is light, but here its kind of dark which
means there might be, what do you think? Caries? And in this case we call it recurrent caries because
theres already an existing restoration. How do I know that theres a restoration on these teeth and not
that its just enamel? Its actually, you can look at, first of all, you can look at the shape. Other than the
shape, its much more radiopaque than enamel should be. So this is enamel. Any metallic component
would make it more radiopaque because the metal is the most radiopaque on a radiograph. Ok? And
whats with this tooth over here. I heard it said. Root canal. So how do I know its root canal because an
area that should be radiolucent is now radiopaque. Ok. I just like to throw in interpretations whenever I
possibly can so I can get used to not only taking the films, but reading them as well.

Slide 6: Pediatric radiography
Now, a pediatric series. Its usually less films. Most of the time, its 13 films. It depends on the size of the
patients mouth obviously and how many films you need to take. Generally, were much more specific
about selection criteria when it comes to pediatric patients and the main reason is because if you look
into the pediatric patients mouth. What is the most obvious difference in the relationship of one tooth
to another as opposed to an adults mouth. Anybody want to take stab at that? Spaces. You can look
into pediatric patients mouth and not have to take any films in the posterior region because theres a
lot of spacing. Especially as the jaw is getting bigger and the teeth arent filling up. So you know we
sometimes call it deciduous teeth space maintainers. You know, to hold the space of the adult teeth.
And a lot of times, you have so much space between the teeth, that you dont need radiographs,
especially bitewings. Because interproximal regions, you can kind of look in. If theres have a reason to
radiograph, we usually do, but full series on pediatric patient is very uncommon. And this stage when we
prescribe radiographs. Theres various ways you can get series of radiographs on edentulous patients.

Slide 7: EDENTULOUS RADIOGRAPHY
First of all, panoramic x-ray is about the easiest thing you can do. And thats an extraoral radiograph that
encompasses from condyle to condyle on one film. And well talk a little bit more panoramic as we get
to that part. You can also do occlusal radiograph which Im going to get specific about. Basically, you use
a number 4 size film and its actually knick named sandwich film because of the way its held in the
mouth. So youre getting birds eyes view or tunnel view, and you can see form buccal to lingual on the
film and if there are any pathologies or retained root tips or anything else you may want to see in
edentulous series, you can see it on an occlusal film. Or you can take films. And its usually about 13 that
you need to cover it. But I can tell you that these are the hardest films you ever want to mount. Its the
hardest jig-saw puzzle because you dont have teeth. A lot of times, you will have a good view of the
anatomic landmarks like here you see maxillary sinus. Here you see nasal region. The mandible is a little
bit more difficult to do but for the most part, I would say that the radiograph that we most likely would
take on an edentulous patient is a panoramic radiograph. Now, there are criteria for acceptable intraoral
radiograph. So let me start his discussion by saying, theres a big difference between perfect and
diagnostic.

Slide 8: CRITERIA FOR ACCEPTABLE INTRAORAL RADIOGRAPHS
Perfect would mean that I could pick up any radiograph that you take and theres nothing on that
radiograph that is listed on this, this list of, or not listed on this list full of criteria so theres no
overlapping, no cutoffs, nothing that would interfere, and its the prefect replication of the area you
want to take. Diagnostic on the other hand, what's the most common use for radiographs in dental
radiography? Diagnosis. So, if it fits the reason why you took the film, I want to take a canine film
because I want to see the entire canine and Im taking periapical because I want to see the apex as well.
But after it take it, is see theres a big cutoff on the film, an area that was not exposed on the film. And
the reason for that is that the central ray is not centered on the film, but I can see the entire canine, do
you think that film would be diagnostic? It would be diagnostic. Its not very pretty, but its diagnostic
theres a difference between diagnostic and being perfect. We would like a perfect radiograph all the
time, but if its at a cost of the patient. In other words if you have to expose the patient to a retake then
you wouldnt have to if you just for diagnostic purposes. Then its better to use it as a diagnostic film and
not go for perfection. So the criteria for acceptable radiograph would include the following. Firs of all, it
has to have proper definition and detail. In other words you need to be able to distinguish enamel from
cementum. You need to be able to distinguish carious lesion rom enamel. You need for it to be without
magnification or geometric distortion of the image. Ok. So that you can actually define what youre
looking at. You also need the right amount of contrast and density. So if the film sits too dark and you
cant see whether the enamel and cementum are differentiated from each other. Or if you cant tell the
difference between pulp and dentin that it lies next to. Because of it being too dark or too light then it
would constitute a retake. So all structures need to be delineated easily from one to the other. Whether
it relies on definition and detail or whether, excuse me, whether it relies on contrast and density. So its
important to know what definition and detail and contrast and density is. You also dont want any
distortion thats created by foreshortening or elongation now foreshortening and elongation are errors
in vertical angulation. So the best way for me to describe vertical angulation is to talk about the sun. And
Im the queen of analogy, so I always use things to compare it to just so that it becomes a little more
understandable to you. I always say that radiography when Im talking it in the lab. Its just a glorified
form of shadow casting. The shadow casting you can do with al flash light and putting your little hand
down on the wall or shadow casting that comes from the sun. So lets talk about the sun for a second. So
if the sun is very high in the sky, during the day, midday, very high in the sky, what does your shadow
look like? If you see one. Its very short, isnt it? Ok. The other side of the coin would be when its
starting to set. The sun is starting to set and its low. What happens to your shadow? Becomes longer. So,
elongation meaning that the tooth appears much longer than it should on the image its usually due to
two little vertical angulation. Get it? The sun is low, you'll get a longer shadow. If you have too much
vertical angulation, too high, you get a foreshortened image. Now the difference between
foreshortened and elongation is pretty simple. The tooth either appears too long or it appears too short.
The better of the two and I dont like to pick an error that works better, but at least in foreshortening,
you see the whole tooth and elongation you dont see the whole tooth. The image is off the base, or
digital sensor base. So you dont want distortion created by foreshortening or elongation because youre
not seeing the tooth as you would see it in the mouth. Ok. If youre periapical film doesnt show the
entire tooth from the incisal edge to the occlusal surface, with at least 2-3mm of bone, 3-4mm would be
better. But at least 2-3mm of bone around the apex, then it doesnt suffice the definition of what a
periapical film does and something is going to be left undiagnosed because its not on the film. Correct?
If the bitewing radiographs dont show at least the crowns in both arches then they usually show a little
bit more than the crown. Going beyond because theyre also used to look at the bone height. So you
want to go beyond the CEJ. Land you usually you do see both. But lets say we see more of the maxilla
than the mandible because of improper placement in the patients mouth. Lets say, lets say in some
cases we might see more mandible than maxilla well then youre not seeing what you should be seeing
because you should see it equally it on both sides. So if you dont see both arches as much as to the
other, or at least enough to diagnose interproximally anything. Then you would, then would constitute a
retake. So if the film youre looking at or the image that youre looking at does not qualify as a diagnostic
radiograph, it probably means that it doesnt fulfill one of the criteria were talking about now.

Slide 9: CRITERIA FOR ACCEPTABLE INTRAORAL RADIOGRAPHS (CONTINUED)
Now, the full mouth series of radiograph. If the full mouths series is taken, and thats a big IF in this
point of time. Because we dont usually take a full mouths series unless thats indicated for that patient.
Unless the patient hasnt taken films in six years. And have tons of restorations, history of root canal
therapy. Well then were going to want to take a full mouth series. If the full mouth series is taken, and
the entire process doesnt show both maxilla and mandible, that would constitute a retake. That does
not fulfill the criteria for acceptable radiographs. All interproximal surfaces should be seen without
overlapping. So what does overlapping basically mean? Overlapping means that the interproximal
structures are overlapped over each other. So, when youre talking about interproximal, what dimension
of the tooth are you looking at? Are you looking at the height or width? If youre talking about
overlapping of structures. Well, youre talking form right to left. So Right to left is mesial to distal, thats
the width, right? Right to left. So if the error is overlapping then it has to do something with horizontal
angulation. Right? Vertical angulation is not going to produce overlapping. Horizontal angulation, and
the best way to describe this is if, have any of you ever been to Rome? In Rome, theres a saint peters
square right? Where the pope is. If you stand in the middle of that square, youll only see in this very
one spot, youll only see about 9 pillars going around the square. However, if you move off that square
and change your horizontal view, youll see about 9 other columns behind those first columns you saw
in that one spot. Thats the difference being in a certain, in one horizontal as opposed to another
horizontal angle. In our case, we dont see too much horizontal angulation. We dont see too little
horizontal angulation. We say incorrect or improper horizontal angulation. So what film do you think is
the most important to avoid horizontal angulation? The bitewing. Why? Because youre looking, what
youre depending on the bitewing to do is to show you interproximal areas. If you have horizontal,
improper horizontal angulation or overlapping then you wont see the interproximal areas clearly. And
at this point in time our profession, I would say in most cases we take bitewings on most of the patients
and then add periapicals as needed. Its not as often as taking FMS despite what might be said by
insurance company. It has more to do with what patients need at that point in time. So bitewings, we
have to rely on bitewings very often at this point in time. So we want to make sure that bitewings do not
have interproximal overlapping. The x-ray beam should be centered in order to avoid collimator cut off.
So what does that mean? That means if you have, right now were using rectangular collimation more so
than circular collimation especially in the teaching institution. So that means that the central ray you talk
about. When you talk about aiming at the film, that the true thing about the film? That central ray
should be centered at the film packet so that the entire packet is covered. If its not centered, if its too
far to the left, too far to the right, too far to the superior, too far to the inferior, part of that film is going
to get cut off. And thats what we call collimator cut off. And Ill go into more about that because that,
you definitely need to see. The radiograph should not have an artifact. Whats an artifact in general? Its
actually just something on the film thats not in the patients mouth. I say an artifact, not a fact. So If you
have over bending of the film packet, if you have that little round radiolucency thats caused by having
orientation done at the apex as opposed to occlusal surface. Thats going to create what looks like
periapical radiolucency or periapical pathology thats not really. So its something on the film that is not
actually inside the patients mouth. But unless you are aware of it, you wouldnt know that it its not in
the patients mouth. Lets say I over bend the film packet and I have a black diagonal line over the root.
What do you think that could be confused with? A root fracture. So these are the thing you want to try
to avoid so you dont or you do is could say. You dont have to, you do not misdiagnose. Ok? The film
should be processed properly. Well, this would only apply to conventional film. This wouldnt apply to
digital radiography. But you can take the best series of films, and if you dont process them properly,
theyre still not going to be diagnostic. And thats probably one of the most helpless situations that youll
ever find yourself in especially you know, I remember back in the day, when I used to work for or work
with a dentist whos trained in the armed forces. And at that time, they put their developer and fixing
solutions they were not automatic processors. They put the developer and fixer solution reversed. So
their fixer was to the left and developer was to the right. And the water was in the middle. Right. We
were taught the opposite it. So when I got there no body told me that. I knew, I just knew I took the best
series of my life. Because I was out to impress this guy, right? And I started processing the films and they
came out all clear. 18 films completely clear. Why? Because I put it in the fixer before I put it in the
developer because I was taught not only process but to read from left to right. And he did it completely
different. So, processing could really be a problem. Its not just Im going to take these films and it
doesnt matter how you process them. It does matter how you process them unfortunately. And it
matter to the patient too because that patient had to be exposed all over again and I was not happy.
Shed couple of tears on that one.Alright, so, now were going to be talking bout paralleling techniques.
Theres a difference and youve heard of both being mentioned. The paralleling versus bisecting. There
are two types of technique you can use in intraoral radiograph. The paralleling technique is based on the
premise of a 90 angle.

Slide 10: PARALLELING METHOD
So the vertical dimension is coming from the tooth and the film being parallel. So when youre using the
paralleling technique, the film is parallel to the tooth like this and then the central ray is directed so that
it is perpendicular to both which creates that 90 angle.

Slide 11: FFD/CENTRAL RAY POSITIONING WITH THE BISECTING/PARALLELING TECHNIQUES
One of the main advantages of the paralleling technique is that. The image is the close to the tooth if
you were to look at the tooth clinically. Because its based on a 90 angle. Ok. It also gives a lot less
exposure to the thyroid gland and the lens of eye because theres less, because theres very little vertical
angulation thats used when you see paralleling technique. It pretty much doesnt go maybe a positive
20 or a negative 20 depending on your patients mouth. Obviously theres going to be more steep than
others. So this also would be a paralleling technique. So you can film parallel to the tooth. And the
central perpendicular to both. If you compare that. Let me just say that. One of, also one of main
advantage of the paralleling technique is that you get dimensional accuracy. So in other words, if youre
comparing the buccal roots of a third molar to the palatal root of that third molar. Its actually is in the
same relationship as you would see it, or as close as you can get it to what it actually appears in the
mouth.
Now, the other technique which is called the bisecting technique is based on whole lots of different
principles. And in this point in time, in this country, we basically only use bisecting technique when cant
use the paralleling technique. What does that mean? That means we cant get the film parallel to the
tooth. If the patient has a very low palate, if the patient has what I call the steeple palate. You know the
steeple of the church goes up really high? But the sides of it drop really low, so you cant get the film in
there in the parallel position. First thing I usually do is decrease the size with the film. But if that doesnt
work, I only go for a 1. Because if you use zero on an adult, it won't even get a whole tooth in there. So if
you decrease the size of the film, and it still doesnt work, you may have to use the bisecting technique.
And the bisecting technique is based on the principle that the film is held on an angle and is as close to
the tooth as possible. The object film distance on the paralleling technique is not as important as the
parallelism between the tooth and the film. So, with bisecting angle technique, the film placement is
much easier. Because all you have to do is placed the film as close to the tooth as possible. Its the
second principle which is much more difficult. Because what you need to do, because the film and the
tooth are not parallel is you have to find a happy medium between the two. So you take the angle the
tooth and the film, you cut it in half which is where the bisector comes into the title of the technique
which is a bisecting angle. So you bisecting angle and then you shoot the central ray so that its
perpendicular to the bisector. So its like going towards the happy medium and not either the film or the
tooth. This technique gives you a lot of distortion in the vertical dimension, is more opt to give you
foreshortening and elongation, and also gives you dimension distortion. The extra added attraction is
that, you also get more exposure because of the angles that youre suing, the steeper vertical angels to
the lens of the eye and thyroid gland. Ok? There are various film holders. And if you notice, I have whole
bunch of film holders here. These are called stabes. No my great-grandfather didnt invent them. The
way Dr. Friedman likes to tell people.

Slide 12: FILM HOLDERS
These are called, these paralleling instruments, these and these by the way, anything with a rod and the
ring can only be used with the paralleling technique. Because the bisecting technique is not based on a
right angle. So these can be used with both paralleling and bisecting. This is a hemostat which some
people. You want to make sure that youre using long nosed hemostat, and not a short one. During root
canal therapy, you sometimes cant get the patient to close down if theres anything in the way. So you
may want to use a hemostat makes sure that patients hand is not being exposed to the radiation. If the
patient is holding it. I dont really love that because the patient has to hold it and the hand gets scatter
radiation. This is called snap-a-ray. Snap-a-ray holds it sort of like a crocodile teeth. The holder that we
use the most is called is an XCP. Its a paralleling instrument. The ones that we use are color coordinated.
So theyre pretty easy to put together. And it helps you to align the central ray which is being directed
by aligning it parallel to the bar here. You notice that film is going to be here, the film is parallel to the
tooth, and then the bar is perpendicular to the both. So aiming of the central ray becomes that much
easier if youre using a paralleling instrument. The film holders that we use, if you noticed, theres no
finger there. No fingers on this list, right? We do not allow patients to hold the film. With the finger. Its
like, if youre taking a chest X-ray and told you to hold the film with your foot. Why would you do that? If
youre takin a film of the tooth, why would you ask your patient to hold it with their finger? Because
having the patient exposed to another part of the body that doesnt need to be exposed. Will you see it?
Even in this building? You might. But it doesnt come from health and safety in terms of radiology is
concerned. Theres Six factors in periapical exposure are not really separated as much for the paralleling
technique as they are for the bisecting. Because in terms of the time, you want to use the time that is
needed for each of those area. We make it nice and easy now because we have icons we can follow on
the new machines. Otherwise you would need it to be posted. So you know what exposure time is.

Slide 13: SIX FACTORS IN PERIAPICAL EXPOSURE TECHNIQUE
if you had to guess, where do you think the least amount of exposure time is needed? And its pretty
much the anterior region because the anterior teeth are thinner than the posterior teeth, and it goes up
as you go back. So the he least amount of time is needed for the anterior region. A little bit more in the
premolar region. The most in the molar region. And its higher in exposure time, in maxillary arch than
mandibular not because maxilla is denser, but theres dense bone coming in there. Ok. The film position
if youre using the paralleling technique, the film has to be parallel to the tooth. And it doesnt matter if
you have to go into palate or into the floor of the mouth to get that. In other words, an increase in
object film distance, its not with the paralleling technique, its not as bad. Its not going to give you
geometric distortion it would with bisecting because the focal film distance that youre using has to be
between 12-16 inches. So the Increase in the film focal distance kind of counter acts the increase in
object film distance. So its not a factor. Not to the naked eye anyway. The point of entry for the
paralleling technique is simple enough. The central ray is directed at the center of the film packet, and
there's no specific film on the spot of the face. It changes for every patient. Because its based on the
initial placement of the film that the film is parallel to the teeth. The vertical and horizontal angulation is
perpendicular to the film packet in both the vertical and horizontal plane ok. And its very important
that the film is also placed parallel to the tooth in both vertical and horizontal plane as well. So it should
be parallel vertically and horizontally at the same time. Ok. In terms of proper positioning, as far as the
parallel technique is concerned, it doesnt matter. The patient basically could be standing on their heads
and especially if youre using paralleling instrument, it does not matter.

Slide 14: PATIENT POSITIONING
However, if you want to see how much vertical angulation is within reason, for the paralleling technique
then the proper position should be that the mid-sagittal plane is perpendicular to the floor and the arch
that youre working on is parallel. So In this case, the mandible is parallel to the floor and, and in this
case the maxilla is parallel to the floor. So its the arch that youre working on should be parallel to the
floor. And we generally take films in an upright position, but if youre in a middle of a procedure. And
you have to take operative film and youre using paralleling instruments. You could do that. It doesnt
matter that the patient is supine or semi supine. Alright? The film placement of the paralleling technique
is such that it should be parallel to the teeth in both the vertical and horizontal plane. Ok? The film
placement also includes the film placement in the holder. So if youre film is not all the way in the holder,
youre also going to get an error. Lets say the film falls out of the holder, then youre not going to get
incisal or occlusal surface. Right?

Slide 15: FILM PLACEMENT
If the film is placed so that the dot is at the apex and not in the holder or in the slot, what I call the slot.
Dot in the slot. It rhymes and it helps to get the dot that the occlusal surface. Because the slot in the film
holder is right here. So that will always be towards the occlusal surface. Ok? You also want to make sure
the patient is closed all the way. Thats as also film placement. Alright? So film placement or error in film
placement is the most common error because theres a lot of different error in the overall terminology
of film placement. Ok so when youre taking a radiograph the radiograph youll be taking in full series of
radiograph. And let me just say when a patient comes in with a film or a tooth thats bothering them,
that tooth should be in the center of the film. If youre taking a series of films, theres certain areas that
should be at the center of the film. So if youre taking a central maxillary central film,

Slide 17: MAXILLARY PROJECTIONS
It should be, the film should be centered between the junction of the two central incisors. This is
actually a circular column. Were using rectangular right now. Basically, youre still going to use that ring
to determine whether the column should be placed. Um, the canine, for the canine film, the film should
be centered on the center of the canine. For premolar, we usually the second premolar should be
centered. For premolar film, you want to get at least the distal of the canine because on a canine film,
theres a lot of overlapping on the distal of the canine. So if you can clear that on a premolar film. It can
give you a better look at the interproximal region there. And for the molar film, its centered on the
second molar. For the bitewing, its usually premolar and molar bitewings. So its centered also on the
premolar, 2
nd
molar. And you can see that, when youre using the paralleling instruments, that the arm
which is also called the aiming arm, it should be parallel to the side of the PID (position indicating
device), and then you want to line it up so it follows the front of the PID.

Slide 18: BITE PROJECTIONS
And for one second, I just want to go back here so you can see the inside of the ring. The inside of the
ring if you were to go closer to it, it has a cut out or template for the rectangular column placement. So
you can use this for circular collimation and also rectangular collimation. So when you see rectangular
collimation, youre not completely on your own, but its a little bit more challenging than round, than
the circular column.

Slide 12: FILM HOLDERS
Because with circular columns, you have an inch worth of room for human error. Because the film is
smaller than rectangular in shape. You have quarter of an inch of make a mistake. With rectangular
collimation, you dont have that. You have to be lined up with the film in the patients mouth each and
every time.

Slide 15: FILM PLACEMENT
Ok so now if that film placement, if the column is not placed properly or if the time is not set properly,
or if your film placement is not correct, youre going to get an error. And these are the common errors in
the bisecting and paralleling techniques. So the first one which Ive mentioned discuss more when you
can see an image of it is called a collimator cut off

Slide 20: COMMON EXPOSURE ERRORS/REMEDIES
Collimator cutoff is caused by central ray not being directed at the center of the film. And it also could
be in any direction. It also can be either shape column. So if you have circular column, youre going to
get a circular cut off.

Slide 21: COLLIMATOR CUTOFF
If you have a rectangular column, youre going to get rectangular or straight cutoff. And the cut off that
existing from rectangular collimation could also look like cutoff that was caused by the lead collar being
too high. When you have cutoff by thyroid collar being too high, first of all its not straight. Second of all,
you can actually see the dots from the threading. So thats how you can tell the difference. Also, if you
curve your film and get a cutoff from the film being curved too much, thats also going to be curved. But
it could happen with rectangular collimation if its caused by placement. So, its not only is it caused by
column not being centered, but it could be caused by film not being centered. So if your film is pushed
too far right or the left, you could also bet collimator cut off. Collimator cut off will end up in a retake or
constitute a retake when it cuts off the area you want to see on the film. If it has nothing to do with
what you want to see on the film, then its not truly a collimator cut off. It doesnt look pretty but its
not a true collimator cut off. Film reversal is a little different than what youre going to see today
because the pattern on lead foil is different. You know that you have lead foil inside the packets, and
that lead foil is placed at the back of the packet. So the back the film packet is the two colored sided film
as oppose the light side of the film. If you place the lead foil in the front of the film, as opposed to
behind the film, then youll get whats called film reversal.

Slide 22: FILM REVERSAL
Films that are reversed are usually going to be much lighter that they should be and they will have the
same geometric pattern thats usually on the lead foil superimposed on them. Ive never met a reversed
film thats actually diagnostic. Because the overall quality of it in terms of lightness is way too light for
you to see anything on the film, and then you have this geometric pattern that just adds to the
diagnostic quality of the film or decrease in the diagnostic quality As I said about film placement, theres
lot of different ways you can get film placement error. One of the most common is called an inadequate
closure. So if your patient doesnt close on the both sides of the bite piece and isnt holding the bite
piece on both sides. Youre going to get this black area above or below depending on if youre on
mandible or maxilla, and what happen is, you dont get the apexes because the film is not depressed
enough either in the palate or the floor of the mouth. That would be what we call inadequate closure,
and it is an improper placement error.

Slide 23: Improper Film Placement
And now. So in that textbook, the former textbook. I dont like to call it a Stabulas textbook because
then Im just giving myself credit. Thats not what I want to do. So it that textbook, in the back of the
textbook theres an appendix, that actually lists cause of error and how to remedy it. It has in a nice
table which is much easier way to study it or to understand it. So you might want to use that. Its an
appendix in the back of the textbook. So for your case, itll be at the back of the textbook on the
vitalbook.

Slide 24: HORIZONTAL OVERLAP
Horizontal overlapping, we already explained. The central ray should be directed, so that it is going
through the interproximal regions, and not crossing over the interproximal regions. If it crosses
interproximal regions, you get overlapping of the interproximal structures. Ok? If you over bend the film
packet to the point where youre cracking the emulsion. Now it doesnt meant that youre adding,
youre using the flexibility of the film packet. Because unless the emulsion is cracked, you wont get the
black line. So, what you need to do is not manipulate the film packet as much. So that you dont create
an artifact that looks like that. If its too dark it would be overexposed. If its too light, it would be
underexposed which is very similar with overdevelopment or under development. Usually you cant tell
the difference if youre just looking at the film.

Slide 25: OVERBENDING OF THE FILM PACKET
So most of the time, you have to retrace your steps and see what caused it. In any event, its not
diagnostic because its either too light or too dark. Double exposure is using the film packet twice. And
this is what I call a classic double exposure because this film packet was used for anterior film and a
posterior film. So it was used once for canine, and once for premolar. And they follow each other.

Slide 26: UNDEREXPOSURE/OVEREXPOSURE
So the best way to avoid that is to makes sure you separate your exposed film with unexposed films.
And what I usually do is just remove that barrier envelop. You know that barrier thats on the film. If I
remove that right away, I can easily tell the difference between the films that have barrier which havent
been exposed.

Slide 27: DOUBLE EXPOSURE
And film thats exposed with the barrier removed. So its really paying attention to the detail double
exposure is the worse. Because you have to take two. Because you have to retake two. Under certain
circumstances. Well finish his discussion on Thursday. Um and then go into the other accessory
techniques.