Chapter

 3
Radiographic Techniques

Radiographs, when used with the patient’s  case history and clinical examination, are
one of the most important diagnostic aids available to the dentist. Diagnostic  
radiographs reveal evidence of disease that cannot otherwise be found. They also play
a major role in forensic identification.

This chapter will provide information about taking periapical and bitewing radiographs.
Below is an illustration of a diagnostic full-­‐mouth  series which consists of 15 periapical
(PA) images and 4 bitewing (BW) images which are outline in orange.

Suzanne  Roy  
Chart  #  2344  
4/3/2014  

Full mouth series

Bitewing  (BW) Radiographs show Periapical (PA) Radiographs show the

details of the upper and lower teeth in whole  tooth from the crown to 2-­‐3mm
one  area of the mouth. Each BW shows beyond the end of the root to where
a tooth from its crown to about the the tooth is surrounded by alveolar
level  of the supporting bone. Bitewings   bone.  Each PA shows the full tooth
are used to detect decay between teeth dimension and includes all the teeth in
and  changes in bone loss caused by one portion of either the upper or lower
periodontal (gum and bone)  disease. jaw. Periapical radiographs are used to
detect any abnormalities of  the root
structure and surrounding bone
structure.

1
There are two types of techniques used for periapical radiographs: bisecting angle, and
paralleling.

The bisecting technique may have to be used for patients unable to accommodate the
film positioning  device used in the paralleling technique. These patients may include
adults with low palatal vaults and children. Disadvantages to the bisecting technique
include image distortion, and excess radiation due to increased angulations exposing the
eyes  and thyroid.

Paralleling technique provides less image distortion, and reduces excess radiation to the
patient. When the film is parallel with the long axis of the tooth, the image looks the
same as the tooth itself. There is no distortion.

Film

The paralleling technique is the preferred method, and will be illustrated throughout
this chapter.

Diagnostic images show the following characteristics:

• Good contrast and density
• No  image distortion

2
What is  Density and Contrast?

Density is the overall darkness (blackness) of an image. Contrast is the difference in

lightness and darkness between areas on a radiograph.

The goal in dental radiology is to use techniques that require the least amount of
radiation exposure to produce images  with the right amount of density and contrast.
To better understand density and contrast, let’s  look at some dental radiographs.

The pulp is darker (radiolucent) than the root of the tooth. The enamel is lighter
(radiopaque) than the rest of the  tooth. The lightest areas are amalgam restorations.
Notice  the difference in the shades of grey between the root and bone areas. This is
contrast. Without contrast, you would not be able to see any differences in dental
images.

Examples of diagnostic  PAs with good density and contrast

3
How does  this happen?

Each of the oral structures in the path of the X-­‐ray  beam has different levels of
penetration. Tooth enamel and metallic restorations (amalgams, crowns, etc.) are very
dense, and deflect X-­‐rays  preventing them from reaching the film. Tooth enamel and
amalgams look white (radiopaque).

Tissues and bone are less dense and allow more X-­‐rays  to reach the film. Therefore,
tissue and bone look darker (radiolucent). The different levels of penetration of the X-­‐
rays result in differences in density on the images.

Density and contrast is also affected by how close the PID is to the patient’s  face. Once
the X-­‐rays  pass through the PID, there is a normal widening or spreading of the X-­‐ray  
beam, similar to what occurs when a flashlight is moved further away from a wall. You
should keep this in mind when you position the PID for an exposure.

The closer the end of the PID is to the patient’s  face, the less X-­‐ray  spread. The results
are better contrast  and density of a radiograph, and a smaller area of tissue being
exposed to radiation. The XCP ring should be close to the patient’s  face, and the PID
close to the ring of the XCP.

XCP ring and PID close to the face. This image shows good
contrast and density.

PID is not close to face. This image does not show good contrast and density.

4
 Differences in density give  the  contrast needed in a diagnostic  image.

Example of a diagnostic bitewing series with good density and contrast

The information in this chart may be helpful if you are not getting radiographs with good
density and contrast.

Problem Cause How to Correct

Image too dark • kV too high • Reduce kV
• Exposure time too long • Reduce exposure time
• Machine may need
calibration
(trained factory service person must
check)

Image too light • kV too low • Increase kV

• mA too low • Increase exposure time
• Not  enough exposure • Increase mA if unit is not
time preset
• X-­‐ray source too far • Hold button down for entire
from patient exposure
• Place the XCP ring close to
patient’s  face and the PID
close to XCP ring
• Increase mA (if unit is able to
be adjusted)
• Increase exposure time if
indicated by size of patient

No  image • X-­‐ray unit not on • Check on/off switch

• Short circuit • Check for electrical problems
• Film never exposed • Keep  exposed and not
exposed films separated

5
What is  image  distortion?
Distortion is any change in the size or shape of a tooth on a radiograph. If the image of
a tooth looks larger or smaller than it really is, it is distorted. This is caused by incorrect
vertical angulation.

What does  vertical angulation mean?

Vertical angulation is when the PID is placed in an upward or downward position
anywhere along the line in this picture.

   

Look at these radiographs. See if you see any distortion.

A B C

A: Elongation -­‐ The image on the radiograph is longer than the actual tooth size.

B:   Foreshortening -­‐ The image on the radiograph is shorter than the actual tooth size.

C: No significant image  distortion -­‐ The size of the tooth and the image on the
radiograph are approximately the same.

6
Another way to understand distortion is to shine a flashlight on your fingers. Think of
the flashlight as the PID and the shadow of your fingers as the image that appears on
the X-­‐ray.

Elongation
Hold your hand next to a plain, smooth wall. Shine the flashlight below your hand on
your wrist. See how the shadows of your hand and fingers look longer than they really
are.

Foreshortening
Now  raise the flashlight and shine the light above your fingers. See how the shadow of
your hand and fingers look much shorter than they really are.

7
No Distortion
Now  direct the flashlight  so the light shines above your knuckles. See how the shadow
of your hands and fingers are now approximately the same length as your hand and
fingers.

How do you prevent  distortion?

If you use a film positioning device like the XCP, you rarely get distortion of the image.
However, if you are not using the XCP, you must pay attention to the correct vertical
angulation of the PID.

Elongation and foreshortening  are the result  of vertical  angulation problems.

The XCP eliminates the need for  the operator to determine the vertical angulation. It
simplifies  X-­‐ray  beam alignment, and you get radiographs with no distortion.

When using the XCP, it is important to keep the patient’s  chin parallel to the floor, and
place the film as close as parallel to the teeth to ensure proper  vertical angulation.

8
What is  parallel?

To understand what parallel means, think about the rails of a train track. No  matter the
distance or curve of a train track, the rails are always the same distance  apart. The rails
are parallel.

Look at the photo on the left, the film is placed parallel to the mandibular molars…just
like train tracks. The PID is parallel with film. In the photo on the right, the film is not
placed parallel to the mandibular molars. The PID is not parallel with film.

PID, teeth, and film are parallel. PID, teeth, and film are not parallel.

The paralleling technique reduces image distortion. The paralleling technique will  be
illustrated throughout this chapter.

9
 XCP Film Positioning Devices

Use the yellow XCP for taking Use the blue XCP for taking radiographs
radiographs of posterior teeth. of anterior teeth.

Purposes  of  film  positioning  devices:

• Used to hold a film in the mouth.
• Keeps  the film in position during an exposure.
• Eliminates the need for patient to stabilize film.
• Aligns film, tooth, and aiming ring in a parallel position.

When the PID (cone) is aligned with the  aiming ring of the XCP, the central-­‐ray  will be
perpendicular to the tooth and the dental film.

Toot Central x-­ray

h   beam

PID

Dental Film

Aiming
ring

10
The XCP makes it  easier for the operator to determine vertical and horizontal angulation for
radiographs.   It simplifies X-­‐ray  beam alignment, and you get radiographs with no distortion.

Tip: It is critical you know how to correctly place the film in the mouth to assure diagnostic
radiographs.

Central x-­ray
beam

Film

For taking periapical radiographs on most adult patients, you need size 2 film for posterior
areas, and size 1 or 2 for anterior areas. For children with small mouths, you will need size 0
film. However, if the child’s  mouth is large enough to accommodate size 1 or 2 film, and the
child is cooperative, use the larger size film.

11
Film is placed in the biteblock of the XCP so that the white side (front) of the film packet faces
the teeth. The colored  portion (back) of the film is against the biteblock.

Fron Bac
t   k

When the film is positioned correctly in the XCP, you can look through the ring and see the
white side of the film packet centered in the opening.

12
Now  would be a good time to briefly review key dental anatomy terms that are helpful when
taking dental images.

Dentin-­Enamel Junction  (DEJ)

Cemento-­Enamel Junction  (CEJ)

Cementum

Alveolar Bone

Apex

• Alveolar bone: thickened ridge of bone that contains the tooth sockets.
• Apex: the tip  of a root. The plural for apex is  apicies.
• Cementum: very thin layer that covers the roots.
• Cemento-­‐Enamel  Junction  (CEJ): the place where the root and crown meets.
• Crown: part of the tooth above the gum line that is covered by enamel.
• Dentin: bone-­‐like  substance that makes up most of the tooth. It is found  under the
enamel in the crown and under the cementum in the root.
• Dentin-­‐Enamel  Junction  (DEJ): area of the crown where the dentin and enamel meet.
This is important for diagnosing interproximal caries (decay).
• Enamel: covers the crown.
• Pulp chamber:   found under the dentin, and contains the blood vessels, nerves and
connective tissue that provide nutrients to keep the tooth alive.
• Root: part of the tooth that extends into the upper (maxilla) or lower (mandible) jaw.

13
Two basic rules of taking dental radiographs are:
1. The central beam should pass through the area to be examined;
2. The X-­‐ray  film should be placed in position so as to record the image with minimal or no
distortion.

Using the XCP will help you follow these two rules.

The next section of this chapter shows placement of the film and PID to take diagnostic PA
radiographs using the paralleling technique.

14
 Maxillary Molar Periapical (PA) Radiograph
Film Pacement:
• Center film horizontally in yellow XCP
• Position distally to include all of the molars
• Film should not be touching the teeth
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• All crowns and roots of molars  are visible
• 2-­‐3mm  above apicies of molars
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open

Maxillary Premolar Periapical (PA) Radiograph

Film Placement:
• Center film horizontally in yellow XCP
• Position mesially to include the distal half of the canine
• Film should not be touching the teeth
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• All crowns and roots of premolars and distal of canine are visible
• 2-­‐3mm  above apicies of premolars
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open

15
 Maxillary Canine Periapical (PA) Radiograph
Film Placement
• Center film vertically in blue XCP
• Position directly behind  the canine
• Film should not be touching the teeth
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• Crown and root of canine are visible
• 2-­‐3  mm above apex  of canine
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open

Maxillary Incisor Periapical (PA) Radiograph

Film Placement:
• Center film vertically in blue XCP
• Position directly behind the maxillary centrals
• Film should not be touching the teeth
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• All crowns and roots of central incisors are visible
• 2-­‐3mm  above apicies  of central incisors
• Interproximal alveolar  crest, and surrounding bone region
• Contact areas open

16
 Mandibular Molar Periapical (PA) Radiograph
Film Placement:
• Center film horizontally in yellow XCP
• Position distally to include  the 3rd molar region
• Place film closer to the teeth because the floor of the mouth is deeper
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• All crowns and roots of molars are visible
• 2-­‐3mm  below apicies of molars
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open

Mandibular Premolar Periapical (PA) Radiograph

Film Placement:
• Center film horizontally in yellow XCP
• Position to include the distal half of the canine
• Push back the tongue, and align the film parallel with the teeth
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• All crowns and roots of premolars and distal of the canine are visible
• 2-­‐3mm  below  apicies of premolars
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open

17
 Mandibular Canine Periapical (PA) Radiograph
Film Placement:
• Center film vertically in blue XCP
• Position behind the canine with bottom edge under the tongue
• Push back the tongue, and align the film parallel with the teeth
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• Crown and root of canine are visible
• 2-­‐3mm  below  apex  of the mandibular canine
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open

Mandibular Incisor Periapical (PA) Radiograph

Film Placement:
• Center film vertically in blue XCP
• Position directly behind central incisors with bottom edge under the tongue
• Push back the tongue, and align the film parallel with the teeth
Positioning  Indicator  Device  (PID):
• Place XCP ring as close to face as possible
• Align PID close to XCP ring
Radiograph should show:
• All crowns and roots of central incisors are visible
• 2-­‐3  mm below  apicies  of the mandibular incisors
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open

18
Bitewing  Radiographs

BW images should show:

• All crowns for the maxillary and mandibular molars are visible
• Interproximal alveolar crest, and surrounding bone region
• Level occlusal plane
• Contact areas open

Patient Positioning
The patient’s  head needs to be positioned so the chin is parallel to the floor.   The PID usually
has a line on the side. That line should line up with the occlusal plane.

Occlusal Plane

Level  Occlusal  Plane

For bitewing radiographs, maxillary and mandibular arches should show an equal amount from
the occlusal plane.

Occlusal
Plane

v
Correct:   You want to see an equal amount of maxiliary and mandibular arches..

Occlusal
Plane
Incorrect:   You are not able to see an equal amount of maxiliary and mandibular arches.

Tip: Remember to look into a patient’s  mouth before taking a radiograph. Teeth may be
crowded or rotated. You will have to adjust for individual differences.
19
Taking Bitewing  Radiographs Using XCP

You use the red XCP for bitewing radiographs.

Film Placement for Bitewings

Place the film horizontally in the biteblock. The front (white) side of the film packet faces the
lingual surfaces of the teeth. The back (colored) side of the film packet is placed against the
biteblock.

Front Back
t  

When you look through the ring, you should see the white side of the film packet centered in
the opening. The film should be placed in the holder so the distance from the front edge to the
back edge of the film is the same.

20
 Molar Bitewing  (BW) Images  Using  XCP

Film Placement: • The middle of PID is placed at the

• Center horizontally occlusal surface
• Position distally to include the last Image should show:
erupted tooth in the arch • All crowns for the maxillary and
• Place front edge of the film at the mandibular  molars are visible
distal of 2nd premolar • The distal of the 2nd molar and distal
Positioning  Indicator  Device  (PID): of the 2nd premolar should be visible
• Place XCP ring close to patient’s • Interproximal alveolar crest, and
face, and PID close to XCP ring surrounding  bone region
• Central ray directed between • Contact areas open
maxillary first and second molars • Level occlusal plane

Premolar  Bitewing  Image  Using  XCP

Film Placement: • The middle of PID is placed at the

• Center horizontally occlusal surface
• Front edge includes the distal of the Image should show:
canine • All crowns for the maxillary and
• Place front edge of the film across to mandibular premolars are visible
the opposite arch anteriors • The distal of the mandibular canine
Positioning  Indicator  Device  PID) is visible
• Place XCP ring close to patient’s • Interproximal alveolar crest, and
face, and PID close to XCP ring surrounding  bone region
• Central ray directed between first • Contact areas open
and second premolars • Level occlusal plane

21
 Molar Bitewing  Image Using BW  Tabs

Film:
• Center horizontally
• Position distally to include the last erupted tooth in the arch
• Place front edge of the film at the distal of 2nd premolar
Positioning  Indicator  Device  (PID):
• Central ray directed between maxillary first and second molars
• The middle of PID is placed at the occlusal surface
• Angle PID at positive 8-­‐10  degrees vertical
Image should show:
• All crowns for the maxillary and mandibular molars are visible
• The distal of the 2nd molar and distal of the 2nd premolar should be visible
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open
• Level occlusal plane

Corner   White  
of the of eye
mouth

               

Tip: Put yourself at the back of  

of tthe
he  PID and look at the line on the PID. For molar
bitewings, the front edge of the PID should be placed over the corner of the mouth
to prevent cone cuts. The central ray marker on the PID should be lined up with the
white part of the patient’s   eye. This will help to open up the contacts between the
molar teeth.

22
 Premolar  Bitewing  Image  Using  BW  Tabs

Film:
• Center horizontally
• Front edge includes the distal of the canine
• Place front edge of the film across to the opposite arch anteriors

Positioning  Indicator  Device  (PID):

• The middle of PID is placed at the occlusal surface
• Central ray directed between first and second premolars
• Angle PID at positive 8-­‐10  degrees vertical

Image should show:

• All crowns for the maxillary and mandibular premolars are visible
• The distal of the mandibular canine is visible
• Interproximal alveolar crest, and surrounding bone region
• Contact areas open
• Level occlusal plane

Tip: To obtain the distal of the canine in the image, angle the anterior edge of the film
across to the opposite arch anteriors.

23
Tip: Put yourself at the back of the PID and look at the line on the PID. For premolar
bitewings, the front edge of the PID should be placed over the ala of the nose to prevent
cone cuts.

Ala of the nose

Tip: The central ray marker on the PID should be lined up with pupil of the  eye  to  open
the contacts between the premolar teeth.

Pupil of the  eye

Tip: Remember, if you do not use XCP when taking premolar and molar bitewings, the
vertical angulation should be positive 8-­‐10  degrees.

24
 25  
 
 
Whether using the XCP or tabs, diagnostic bitewing radiographs show the following
characteristics:
• Good contrast and density
• No  image distortion
• No  overlapping

Diagnostic BW image

What is  overlapping?  

Overlapping looks like there is no space between the teeth or like one tooth is covering
another tooth. If an image shows overlapping interproximal contacts, it is not very
useful to diagnose dental disease.

Look at these bitewing radiographs. See if you can see any overlapping.

Red circles show overlapping. Green circles show open contacts.

26
How does  overlapping  happen?

Overlapping happens when X-­‐rays  are not properly directed through the interproximal
spaces or structures.

Incorrect horizontal angulation causes overlapping.

Correct horizontal angulation results in no overlapping.

To visualize where to direct the central ray, look at these photographs of typodonts with
red arrows.
• Molar bitewings: the central ray is directed through the contact areas
between the maxillary first and second molars.
• Premolar bitewings: the central ray is directed through the contact areas
between the maxillary first and second premolars.

Molar Bitewing Premolar Bitewing

27
 This set of bitewing images discloses no overlapping in the region of the mouth under
study.

How does  overlapping  happen?

Overlapping happens when X-­‐rays  are not properly directed through the interproximal
spaces or structures. If interproximal areas are slightly overlapped, the radiograph may
still be diagnostic. However, you must be able to see the DEJ (dentin-­‐enamel  junction)
of each tooth.

Dentin-­‐Enamel Junction (DEJ)

Dentin-­‐Enamel Junction (DEJ)

Dentin-­‐Enamel Junction (DEJ)
 

Dentin-­‐Enamel Junction (DEJ)

)  

When using the XCP, errors can occur by improper horizontal alignment of the film.
These errors can be avoided by placing the PID in alignment with the teeth so that the
central ray travels directly through the contact area.

When using BW tabs, it is important  to learn how to direct the central ray between
specific teeth to get all the contacts open. Some PIDs may have a line on them to mark
28
the central ray or you can look down the PID and imagine a line down the center of the
cone.

For adult patients, it is recommended that premolar and molar radiographs are taken on
each side. The premolar bitewing should include the distal of the canine. The molar
bitewing should include the distal part of the second premolar and include the distal of
the 2nd molar.

For younger children with primary teeth, use #0 or #1 film, and take one bitewing on
each side. For mixed dentition (if first molar is present), use #2 film, and take one
bitewing on each side.
Size 0 Film

Size 2 Film

29
Here are a few questions to check your understanding about taking quality bitewing
images.

1.What causes overlapping?

a. incorrect horizontal angulation
b. improper vertical angulation
c. not removing a patient’s  partial

2. The central ray should be directed between which teeth when taking a premolar
bitewing?
a. canine and first premolar on the maxillary
b. first and second premolar on the maxillary
c. second premolar and first molar on the mandible

3.What is the correct position of the patient’s  head when taking bitewings?
a. chin extended up towards the ceiling
b. chin down towards the chest
c. chin parallel with the floor

4. The central ray should be directed between which teeth when taking a molar
bitewing?
a. first and second molars on the maxillary  
b. first and second premolar on the maxillary
c. second premolar and first molar on the mandible

Answers to Quiz

1. a. Incorrect horizontal angulation will cause overlapping. The central ray must be
directed through the interproximal spaces or contacts for the radiograph to be
diagnostic.
2. b. The central ray should be directed through the premolars on the maxillary for the
contacts to be open when taking a premolar bitewing.
3. c. The patient’s  chin should be parallel with the floor to assist  in getting the correct
angulation. This is especially important if you are not using an XCP.
4. a The central ray should be directed through the first and second molars on the
maxillary for the contacts to be open when taking a molar bitewing.

30
Radiograph Technique Errors

It is important to determine the cause of an error so you can correct your technique and
prevent it from happening again.

Blurred Image

Problem Cause How to Correct

The image on this Blurring is caused by Make sure the film is stable, and the
radiograph is blurred. movement of the X-­‐ray head is not moving. Ask the
The image is said to be film, the patient, or patient not to move during the
distorted. the X-­‐ray head during exposure. If there is no movement,
exposure. there should be no blurring.

Black  lines or streaks over the tooth image

Black lines

Problem Cause How to Correct

A radiograph with Lines or streaks can Avoid sharply bending the film. Use
dark lines may not be happen when a film a film positioning device. This will
useful because it is sharply bent before reduce the need for bending films.
changes the image or during film
under study. placement.

31
Double  image

Problem Cause How to Correct

The images on the A double image can It is a good idea to put exposed
radiograph overlap result from films in a different place than
each other. accidentally exposing unexposed  films.
the same film twice.

Tip: Place exposed films on a paper towel or in a paper cup. This keeps them away from
unexposed films, and they are less likely to get mixed up.

Superimposed  image

Problem Cause How to Correct

Teeth are not clearly The patient’s  partial Be sure to examine the patient’s  
visible because of denture was left in mouth before taking a radiograph.
white, superimposed the mouth during the Have the patient take out any
images. exposure. removable appliances like dentures,
partials, and orthodontic retainers.

32
Image is too light

Tire tracks or
waffle pattern
 

Problem Cause How to Correct

Tire tracks or waffle The backside of the Be careful when placing the film
pattern appear on a film packet was packet in a patient’s  mouth. The
radiograph. placed next to the white side of the film packet should
teeth. The tire tracks be placed next to the teeth. The
are from the lead back of the film is against the
layer in the film biteblock.
packet.

No image on radiograph

Problem Cause How to Correct

The film is clear. No X-­‐rays exposed Be sure  X-­‐ray unit is on when taking
Nothing  is on the the film. radiographs. Keep  exposed and
radiograph. unexposed film separate.

33
What is  a cone  cut?

Cone cuts appear as a clear area on traditional radiographs after processing, due to the
lack of x-­‐ray  exposure in the area of the cone cut.

How does  a cone  cut happen?

This happens because the PID is not correctly positioned relative to the film. The beam
of X-­‐rays  does not completely  cover the film.

The shape of the PID cut depends on the type used when exposing the film. For
example, if a round PID is used, a curved cone cut will appear. Square cone cuts occur
when using a rectangular PID. To correct this error, the PID should completely cover the
dental film.

Remember to be careful when assembling the XCP to make certain that the entire
dental film can be seen while looking through the indicator ring.

34
How does  a cone  cut happen?

This happens because the PID is not correctly positioned relative to the film.   The beam
of X-­‐rays  does not completely cover the film.

Cone cut

No cone  cut

Tip: Always check to see if the beam of X-­‐rays  completely covers the film.

Anterior periapical radiographs can also have cone cuts if the proper technique is not
used. This radiograph is not diagnostic because the apices of maxillary central and
lateral incisors cannot be seen

Maxillary anterior PA with cone cut

35
How does  this happen?

The image shows a cone  cut because the PID was directed at the incisal edge instead of
the middle third of the teeth.

There would have been no cone  cut if the PID had been correctly positioned.

Tip: Using a XCP would help eliminate cone cutting.

36
What happens  if  you have  a cone  cut,  but not under the area  of study?

You have been asked to take a maxillary anterior PA so the dentist can examine the
apical area of the central incisors.

Here are three radiographs. Would they be considered useful for diagnosis?

If the cone  cut is the only technique error, and the area under study is shown on the
image, the radiograph may be diagnostic. The root and apical areas can be seen. The
density and contrast are good. The images would probably not need to be retaken.

BUT

The cone  cut indicates that you need more practice to visualize where the PID and the
X-­‐rays  are in relation  to the film. The X-­‐rays  must completely cover the film or you will
get a cone  cut.

Now  let’s  look at another periapical radiograph. What do you think about the diagnostic
value of this radiograph?

The X-­‐rays  completely covered the film, so there is no cone  cut.  You can see the apicies,
teeth and surrounding area. The contrast and density are good. There is no distortion
of the image. The size  of the teeth and the image  of the teeth are approximately  the
same. This would  be considered a diagnostic radiograph.  

37
This chart summarizes typical technique errors and how you can correct them.

Technique  Errors,  Causes, and Corrective Action

Technique  Errors Causes How to Correct

Image elongated For maxillary teeth -­‐Adjust vertical angulation
-­‐ Too much negative -­‐Use film positioning device
vertical angulation
For mandibular teeth
-­‐ Too much positive vertical
angulation
Image foreshortened For maxillary teeth -­‐Adjust vertical angulation
-­‐ Too much positive vertical -­‐Use film positioning device
angulation
For mandibular teeth
-­‐ Too much negative
vertical angulation
Overlapped contacts Incorrect horizontal Adjust horizontal
angulation angulation so central ray is
aimed through contacts
Cone cut Improper PID placement -­‐Align PID to cover film
-­‐Use film positioning device
Cone cut with no apex -­‐Incorrect film position -­‐Use film positioning device
-­‐Patient not biting on film -­‐Adjust vertical angulation
positioning device
-­‐Incorrect vertical
angulation
Blurred image Patient, film, or PID moved -­‐Instruct patient to hold still
-­‐Stabilize film with film
positioning device
-­‐Do not expose film if X-­‐ray
head is moving
Occlusal plane on bitewings Incorrect film position -­‐Have patient bite on
runs diagonal across film bitewing tab so occlusal
plane is straight across film
-­‐Position bitewing tabs
horizontal
-­‐Have patient’s  chin parallel
with floor

38
Here are some ideas to help you when taking radiographs.

Be prepared
• Set up the operatory with assembled XCP and dental films.
• Seat and inform the patient about the number of x-­‐rays  you will be taking.
• Remove the patient’s  glasses and any removable appliances.
• Raise or lower the chair to accommodate the operator.
• Place the lead apron and secure the thyroid collar.
• Adjust the headrest to stabilize the patient’s  head.
• Establish an exposure routine to prevent errors and use time efficiently.
What is  an exposure  routine?
• When taking a full series, start with the maxillary right molar, and move across
the maxillary arch to the left  molar. Then, you can drop down to the mandibular
left molar, and move across the mandibular arch to the right molar.
• When taking a bitewing series, start with the right side and take the molar and
premolar bitewings, then take the left side molar and premolar bitewings.
• If you have a patient with a strong gag reflex, begin with the anterior films and
work your way back in the mouth. This sequence allows the patient to get used
to the procedure with a minimum of discomfort, and helps to avoid stimulation  
of the gag reflex.
Gagging
• Be confident and understanding.
• Move quickly so the film is not in the mouth for longer than necessary.
• Try to distract the patient.
• Have patient breathe deeply through the nose or wiggle his/her toes.

Use of cotton rolls

• Place the cotton roll  on the opposite arch  from  the one being  radiographed.
• May be used in any area of the mouth to help support the biteblock.
• Make it more comfortable for the patient to bite.
• Place cotton roll in the place of a missing tooth.

Cotton roll used when Cotton roll placement when

taking anterior PA tooth is missing

39
This completes Chapter 3: Radiographic Techniques. You are now ready to test your
understanding of the information you learned.

40