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PERIAPICAL RADIOGRAPH
DENTAL X-RAYS 
X-rays are produced by “boiling off” electrons 
from a filament (the cathode)and accelerating 
the el to the target at the anode. The 
accelerated x-rays are decelerated by the 
target material, resulting in bremsstrahlung.
History of X-Ray 
DISCOVEY 
 Wilhelm Conrad Roentgen, Bavarian 
physicist, 
discovered the x-ray on 1895. 
 In 1895, German dentist Otto Walkhoff 
made the 1st dental radiograph. 
 In 1895, New York physician made the 1st 
dental radiograph in the united states using 
the skull.
Periapical radiograph
Characteristics of x-rays 
 •Invisible and undetectable by the senses. 
 •No mass or weight. 
 •No charge. 
 •Travel at speed light. 
 •Travel in straight line.
 •Absorbed by matters. 
 •Cause ionization. 
 •Cause certain substances to fluoresce. 
 •Can produce image on photographic film. 
 •Cause changes in living cells.
Radiograph in dentistry 
X-rays in dentistry serves as the most important 
diagnostic tool. 
Radiograph in dentistry are divided into two: 
1. Intraoral radiograph. 
2. Extraoral radiograph.
Inrtaoral radiograph 
 Intraoral X-rays are the most common type of 
X-ray 
 It is used mainly for: 
>Detection of caries. 
>Check the health of the tooth root 
and bone surrounding the tooth. 
>Check the status of developing teeth. 
>Monitor the general health of your 
teeth and jawbone.
Types of intraoral radiograph 
 Bite-wing X-rays : Bite-wing X-rays are used to 
detect decay between teeth and changes in bone 
density caused by gum disease. 
 Periapical X-rays : Periapical X-rays are used to 
detect any abnormalities of the root structure and 
surrounding bone structure. 
 Occlusal X-rays show full tooth development 
and placement
Extraoral radiograph 
 Panoramic X-ray 
 Tomograms 
 Cephalometric projections 
 Sialography 
 Computed tomography,
General guidelines on patient 
care 
 For intraoral radiography the patient should 
be positioned comfortably in the dental chair, 
ideally with the occlusal plane horizontal and 
parallel to the floor. 
 Spectacles, dentures or orthodontic appliances 
should be removed. 
 A protective lead thyroid collar should be placed. 
 Intraoral film packets should be positioned 
carefully to avoid trauma to the soft tissues.
Indications of periapical 
radiography 
 Detection of apical infection/inflammation 
 Assessment of the periodontal statue 
 After trauma to the teeth and associated 
 Alveolar bone 
 Assessment of the presence and position of 
 Unerupted teeth
 Assessment of root morphology before 
 Extractions 
 During endodontics 
 Preoperative assessment and postoperative 
 Appraisal of apical surgery 
 Detailed evaluation of apical cysts and other 
 lesions within the alveolar bone 
 Evaluation of implants postoperatively
Ideal positioning 
requirements 
 The desired tooth and film should be in contact 
or as close together as possible. 
 The tooth and the film should be parallel to 
each other. 
 The film packet should be place vertical for 
anterior teeth and horizontal for posterior and 
sufficient film space beyond the apices should 
be present. 
 They tube head should be placed so the beam 
meets the tooth at right angle. 
 The positioning should be reproducible.
Radiographic techniques 
 • The paralleling technique 
 • The bisected angle technique.
Paralleling technique 
 The film packet is placed in a holder and 
positioned in the mouth parallel to the long 
axis of the tooth. 
 The X-ray tubehead is then aimed at right 
angles (vertically and horizontally) to both the 
tooth and the film packet. 
 To prevent the magnification (since the film are 
located at distance) a large focal spot to skin 
distance, by using a long spacer cone or 
beam-indicating device (BID) on the X-ray set.
Periapical radiograph
A) a short cone and a diverging X-ray beam B) a long cone and a near-parallel X-ray 
beam.
Positioning techniques 
 Selection of appropriate holder 
Incisor and canine - Anterior holder 
- Small film packet 
(22*35mm) 
Premolars and Molars – Posterior holder 
- large film packet 
( 31*41mm) 
Smooth white surface of the film packet must 
face towards the x-ray tube head.
 The patient is positioned with the head 
supported and with the occlusal plane 
horizontal. 
 Packet film position 
Maxillary incisors and canines : positioned 
posterior to enable its height to be 
accommodated in the vault of the palate. 
 Mandibular incisors and canines : 
positioned in the floor of the mouth, 
approximately in line with the lower canines or 
first premolars.
Maxillary premolars and molars : placed in 
the midline of the palate. 
Mandibular premolars and molars : placed in 
the lingual sulcus. 
 The holder is rotated so that the teeth under 
investigation are touching the bite block. 
 A cottonwool roll is placed on the reverse side 
of the bite block. This keeps the film and the 
tooth parallel .
 The patient is requested to bite gently 
together. 
 The locator ring is moved down the indicator 
rod until it is just in contact with the patient's 
face. 
 The spacer cone or BID is aligned with the 
locator ring. This automatically sets the vertical 
and horizontal angles and centres the X-ray 
beam on the film packet. 
 The exposure is made.
Periapical radiograph
Periapical radiograph
Periapical radiograph
Periapical radiograph
Periapical radiograph
Bisected angle technique 
 The film packet is placed as close to the tooth 
under investigation as possible without 
bending the packet. 
 The angle formed between the long axis of the 
tooth and the long axis of the film packet is 
assessed and mentally bisected. 
 The X-ray tubehead is positioned at right 
angles to this bisecting line with the central ray 
of the X-ray beam aimed through the tooth 
apex.
 Using the geometrical principle of similar 
triangles, the actual length of the tooth in the 
mouth will be equal to the length of the image 
of the tooth on the film. 
 Vertical angulation of the X-ray tubehead 
The angle formed by continuing the line of the 
central ray until it meets the occlusal plane 
determines the vertical angulation of the X-ray 
beam to the occlusal plane.
 Horizontal angulation of the X-ray tubehead 
The central ray should be aimed through the 
interproximal contact areas, to avoid 
overlapping the teeth.
Positioning techniques 
 Using film holders 
 The film packet is pushed securely into the 
chosen holder. 
 The X-ray tubehead is positioned. 
 Exposure is made.
Advantages of the paralleling 
technique 
 Geometrically accurate images are produced 
with little magnification. 
 The shadow of the zygomatic buttress appears 
above the apices of the molar teeth. 
 The periodontal bone levels are well 
represented. 
 Periapical tissues shows minimal 
foreshortening or elongation. 
 Crown of the teeth shows approximation of the 
caries.
 The horizontal and vertical angulations of the 
X-ray tubehead are automatically determined 
by the positioning devices if placed correctly. 
 The X-ray beam is aimed accurately at the 
centre of the film — all areas of the film are 
irradiated and there is no coning off or cone 
cutting. 
 Reproducible radiographs are possible at 
different visits and with different operators.
Disadvantages of the paralleling 
technique 
 Positioning of the film packet can be very 
uncomfortable for the patient, particularly for 
posterior teeth, often causing gagging. 
 Positioning the holders within the mouth can 
be difficult for inexperienced operators. 
 The anatomy of the mouth sometimes makes 
the technique impossible, e.g. a shallow, flat 
palate.
 The apices of the teeth can sometimes appear 
very near the edge of the film. 
 Positioning the holders in the lower third 
molar regions can be very difficult. 
 The technique cannot be performed 
satisfactorily using a short focal spot to skin 
distance (i.e. a short spacer cone) because of 
the resultant magnification. 
 The holders need to be autoclavable or 
disposable.
Advantages of the bisected 
angle technique 
 Positioning of the film packet is reasonably 
comfortable for the patient in all areas of the 
mouth. 
 Positioning is relatively simple and quick. 
 If all angulations are assessed correctly, the 
image of the tooth will be the same length as 
the tooth itself and should be adequate (but 
not ideal) for most diagnostic purposes.
Disadvantages of the bisected 
angle 
technique 
 The many variables involved in the technique 
often result in the image being badly distorted. 
 Incorrect vertical angulation will result in 
foreshortening or elongation of the image. 
 The periodontal bone levels are poorly shown. 
 The shadow of the zygomatic buttress 
frequently overlies the roots of the upper 
molars. 
 The horizontal and vertical angles have to be 
assessed for every patient and considerable 
skill is required.
 It is not possible to obtain reproducible views. 
 Coning off or cone cutting occur. 
 Incorrect horizontal angulation will result in 
overlapping of the crowns and roots. 
 The crowns of the teeth are often distorted, 
thus preventing the detection of approximal 
caries. 
 The buccal roots of the maxillary premolars 
and molars are foreshortened.
Positioning difficulties 
 Mandibular third molars . 
 Gagging . 
 Endodontics . 
 Edentulous alveolar ridges . 
 Children . 
 Patients with disabilities .
Digital radiography 
 Digital radiography is a form of imaging x-ray 
where digital X-ray sensors are used instead 
of traditional photographic film. 
There are two major variants of digital image 
capture devices: flat panel detectors (FPDs) 
and high-density line-scan solid state 
detectors.
 Indirect FPDs. Amorphous silicon (a-Si) is 
the most common material of commercial 
FPDs. Amorphous silicon combines with 
caesium iodide(CsI) or gadolinium 
oxysulfide (Gd2O2S), and converts X-rays to 
light.
 Direct FPDs. Amorphous selenium (a-Se) 
FPDs are known as “direct” detectors because 
X-ray photons are converted directly into 
charge.
High-density Line-scan 
Detectors 
 A high-density line-scan solid state 
detector is composed of a photo stimulable 
barium fluorobromide doped with europium 
(BaFBr:Eu) or caesium 
bromide (CsBr) phosphor.
Advantage of digital 
radiography 
 Elimination of chemical processing and 
associated errors. 
 Reduction in radiation dose. 
 Computer storage and archiving of patient 
information. 
 Transfer of images electronically. 
 Image enhancement and manipulation.
Disadvantage 
 Cost 
 Reduced resolution 
 Quality of hard copy prints 
 Image storage 
 Image security 
 Limited size of sensor available 
 Lack of sensor flexibility 
 Lack of training at both undergraduate and 
postgraduate levels.
Comparison of direct digital and 
conventional intraoral radiographs in 
detecting alveolar bone loss 
 Background. Intraoral radiographs are 
important diagnostic aids in periodontics. The 
authors conducted a study to compare 
estimates of bone levels from direct digital and 
conventional radiographic under normal clinical 
use.
 Methods. A full-mouth series of 
conventional radiographs was taken for each 
of 25 subjects who had periodontitis. A long 
cone paralleling technique was used for 
periapical, or PA, images, and a paper sleeve 
with biting tab was employed for bitewing, or 
BW, images. A set of direct 
digital radiographs matching the 
conventional radiographs was taken for each 
subject under the same conditions.
 Results. Examiners measured 857 PA image 
sites and 315 BW image sites matched on 
both radiographic systems. Paired t test 
showed significant differences in bone levels 
between the two systems. 
 conventional PA images were higher in all 
maxillary sextants (P ≤ .02), and 
measurements from digital PA images were 
higher in mandibular anterior sextants (P = 
.007).
 In digital BW images were higher in 
mandibular posterior sextants (P = .002) 
 A χ2 analysis of categorical bone levels 
(normal, early-to-moderate loss or advanced 
loss) showed significant differences between 
the imaging systems in revealing bone levels 
in both PA (P< .04) and BW (P < .001) images. 
 Digital radiographs showed a higher number 
of sites with bone loss than the 
conventional radiographs.
 Conclusions. Under normal clinical use, 
alveolar bone levels revealed on intraoral 
direct digital radiographs differ from those 
revealed on conventional radiographs. 
 Clinical Implications. Intraoral direct 
digital radiographs are not an equivalent 
substitute for conventional radiographs in 
evaluating alveolar bone levels.

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Periapical radiograph

  • 2. DENTAL X-RAYS X-rays are produced by “boiling off” electrons from a filament (the cathode)and accelerating the el to the target at the anode. The accelerated x-rays are decelerated by the target material, resulting in bremsstrahlung.
  • 3. History of X-Ray DISCOVEY  Wilhelm Conrad Roentgen, Bavarian physicist, discovered the x-ray on 1895.  In 1895, German dentist Otto Walkhoff made the 1st dental radiograph.  In 1895, New York physician made the 1st dental radiograph in the united states using the skull.
  • 5. Characteristics of x-rays  •Invisible and undetectable by the senses.  •No mass or weight.  •No charge.  •Travel at speed light.  •Travel in straight line.
  • 6.  •Absorbed by matters.  •Cause ionization.  •Cause certain substances to fluoresce.  •Can produce image on photographic film.  •Cause changes in living cells.
  • 7. Radiograph in dentistry X-rays in dentistry serves as the most important diagnostic tool. Radiograph in dentistry are divided into two: 1. Intraoral radiograph. 2. Extraoral radiograph.
  • 8. Inrtaoral radiograph  Intraoral X-rays are the most common type of X-ray  It is used mainly for: >Detection of caries. >Check the health of the tooth root and bone surrounding the tooth. >Check the status of developing teeth. >Monitor the general health of your teeth and jawbone.
  • 9. Types of intraoral radiograph  Bite-wing X-rays : Bite-wing X-rays are used to detect decay between teeth and changes in bone density caused by gum disease.  Periapical X-rays : Periapical X-rays are used to detect any abnormalities of the root structure and surrounding bone structure.  Occlusal X-rays show full tooth development and placement
  • 10. Extraoral radiograph  Panoramic X-ray  Tomograms  Cephalometric projections  Sialography  Computed tomography,
  • 11. General guidelines on patient care  For intraoral radiography the patient should be positioned comfortably in the dental chair, ideally with the occlusal plane horizontal and parallel to the floor.  Spectacles, dentures or orthodontic appliances should be removed.  A protective lead thyroid collar should be placed.  Intraoral film packets should be positioned carefully to avoid trauma to the soft tissues.
  • 12. Indications of periapical radiography  Detection of apical infection/inflammation  Assessment of the periodontal statue  After trauma to the teeth and associated  Alveolar bone  Assessment of the presence and position of  Unerupted teeth
  • 13.  Assessment of root morphology before  Extractions  During endodontics  Preoperative assessment and postoperative  Appraisal of apical surgery  Detailed evaluation of apical cysts and other  lesions within the alveolar bone  Evaluation of implants postoperatively
  • 14. Ideal positioning requirements  The desired tooth and film should be in contact or as close together as possible.  The tooth and the film should be parallel to each other.  The film packet should be place vertical for anterior teeth and horizontal for posterior and sufficient film space beyond the apices should be present.  They tube head should be placed so the beam meets the tooth at right angle.  The positioning should be reproducible.
  • 15. Radiographic techniques  • The paralleling technique  • The bisected angle technique.
  • 16. Paralleling technique  The film packet is placed in a holder and positioned in the mouth parallel to the long axis of the tooth.  The X-ray tubehead is then aimed at right angles (vertically and horizontally) to both the tooth and the film packet.  To prevent the magnification (since the film are located at distance) a large focal spot to skin distance, by using a long spacer cone or beam-indicating device (BID) on the X-ray set.
  • 18. A) a short cone and a diverging X-ray beam B) a long cone and a near-parallel X-ray beam.
  • 19. Positioning techniques  Selection of appropriate holder Incisor and canine - Anterior holder - Small film packet (22*35mm) Premolars and Molars – Posterior holder - large film packet ( 31*41mm) Smooth white surface of the film packet must face towards the x-ray tube head.
  • 20.  The patient is positioned with the head supported and with the occlusal plane horizontal.  Packet film position Maxillary incisors and canines : positioned posterior to enable its height to be accommodated in the vault of the palate.  Mandibular incisors and canines : positioned in the floor of the mouth, approximately in line with the lower canines or first premolars.
  • 21. Maxillary premolars and molars : placed in the midline of the palate. Mandibular premolars and molars : placed in the lingual sulcus.  The holder is rotated so that the teeth under investigation are touching the bite block.  A cottonwool roll is placed on the reverse side of the bite block. This keeps the film and the tooth parallel .
  • 22.  The patient is requested to bite gently together.  The locator ring is moved down the indicator rod until it is just in contact with the patient's face.  The spacer cone or BID is aligned with the locator ring. This automatically sets the vertical and horizontal angles and centres the X-ray beam on the film packet.  The exposure is made.
  • 28. Bisected angle technique  The film packet is placed as close to the tooth under investigation as possible without bending the packet.  The angle formed between the long axis of the tooth and the long axis of the film packet is assessed and mentally bisected.  The X-ray tubehead is positioned at right angles to this bisecting line with the central ray of the X-ray beam aimed through the tooth apex.
  • 29.  Using the geometrical principle of similar triangles, the actual length of the tooth in the mouth will be equal to the length of the image of the tooth on the film.  Vertical angulation of the X-ray tubehead The angle formed by continuing the line of the central ray until it meets the occlusal plane determines the vertical angulation of the X-ray beam to the occlusal plane.
  • 30.  Horizontal angulation of the X-ray tubehead The central ray should be aimed through the interproximal contact areas, to avoid overlapping the teeth.
  • 31. Positioning techniques  Using film holders  The film packet is pushed securely into the chosen holder.  The X-ray tubehead is positioned.  Exposure is made.
  • 32. Advantages of the paralleling technique  Geometrically accurate images are produced with little magnification.  The shadow of the zygomatic buttress appears above the apices of the molar teeth.  The periodontal bone levels are well represented.  Periapical tissues shows minimal foreshortening or elongation.  Crown of the teeth shows approximation of the caries.
  • 33.  The horizontal and vertical angulations of the X-ray tubehead are automatically determined by the positioning devices if placed correctly.  The X-ray beam is aimed accurately at the centre of the film — all areas of the film are irradiated and there is no coning off or cone cutting.  Reproducible radiographs are possible at different visits and with different operators.
  • 34. Disadvantages of the paralleling technique  Positioning of the film packet can be very uncomfortable for the patient, particularly for posterior teeth, often causing gagging.  Positioning the holders within the mouth can be difficult for inexperienced operators.  The anatomy of the mouth sometimes makes the technique impossible, e.g. a shallow, flat palate.
  • 35.  The apices of the teeth can sometimes appear very near the edge of the film.  Positioning the holders in the lower third molar regions can be very difficult.  The technique cannot be performed satisfactorily using a short focal spot to skin distance (i.e. a short spacer cone) because of the resultant magnification.  The holders need to be autoclavable or disposable.
  • 36. Advantages of the bisected angle technique  Positioning of the film packet is reasonably comfortable for the patient in all areas of the mouth.  Positioning is relatively simple and quick.  If all angulations are assessed correctly, the image of the tooth will be the same length as the tooth itself and should be adequate (but not ideal) for most diagnostic purposes.
  • 37. Disadvantages of the bisected angle technique  The many variables involved in the technique often result in the image being badly distorted.  Incorrect vertical angulation will result in foreshortening or elongation of the image.  The periodontal bone levels are poorly shown.  The shadow of the zygomatic buttress frequently overlies the roots of the upper molars.  The horizontal and vertical angles have to be assessed for every patient and considerable skill is required.
  • 38.  It is not possible to obtain reproducible views.  Coning off or cone cutting occur.  Incorrect horizontal angulation will result in overlapping of the crowns and roots.  The crowns of the teeth are often distorted, thus preventing the detection of approximal caries.  The buccal roots of the maxillary premolars and molars are foreshortened.
  • 39. Positioning difficulties  Mandibular third molars .  Gagging .  Endodontics .  Edentulous alveolar ridges .  Children .  Patients with disabilities .
  • 40. Digital radiography  Digital radiography is a form of imaging x-ray where digital X-ray sensors are used instead of traditional photographic film. There are two major variants of digital image capture devices: flat panel detectors (FPDs) and high-density line-scan solid state detectors.
  • 41.  Indirect FPDs. Amorphous silicon (a-Si) is the most common material of commercial FPDs. Amorphous silicon combines with caesium iodide(CsI) or gadolinium oxysulfide (Gd2O2S), and converts X-rays to light.
  • 42.  Direct FPDs. Amorphous selenium (a-Se) FPDs are known as “direct” detectors because X-ray photons are converted directly into charge.
  • 43. High-density Line-scan Detectors  A high-density line-scan solid state detector is composed of a photo stimulable barium fluorobromide doped with europium (BaFBr:Eu) or caesium bromide (CsBr) phosphor.
  • 44. Advantage of digital radiography  Elimination of chemical processing and associated errors.  Reduction in radiation dose.  Computer storage and archiving of patient information.  Transfer of images electronically.  Image enhancement and manipulation.
  • 45. Disadvantage  Cost  Reduced resolution  Quality of hard copy prints  Image storage  Image security  Limited size of sensor available  Lack of sensor flexibility  Lack of training at both undergraduate and postgraduate levels.
  • 46. Comparison of direct digital and conventional intraoral radiographs in detecting alveolar bone loss  Background. Intraoral radiographs are important diagnostic aids in periodontics. The authors conducted a study to compare estimates of bone levels from direct digital and conventional radiographic under normal clinical use.
  • 47.  Methods. A full-mouth series of conventional radiographs was taken for each of 25 subjects who had periodontitis. A long cone paralleling technique was used for periapical, or PA, images, and a paper sleeve with biting tab was employed for bitewing, or BW, images. A set of direct digital radiographs matching the conventional radiographs was taken for each subject under the same conditions.
  • 48.  Results. Examiners measured 857 PA image sites and 315 BW image sites matched on both radiographic systems. Paired t test showed significant differences in bone levels between the two systems.  conventional PA images were higher in all maxillary sextants (P ≤ .02), and measurements from digital PA images were higher in mandibular anterior sextants (P = .007).
  • 49.  In digital BW images were higher in mandibular posterior sextants (P = .002)  A χ2 analysis of categorical bone levels (normal, early-to-moderate loss or advanced loss) showed significant differences between the imaging systems in revealing bone levels in both PA (P< .04) and BW (P < .001) images.  Digital radiographs showed a higher number of sites with bone loss than the conventional radiographs.
  • 50.  Conclusions. Under normal clinical use, alveolar bone levels revealed on intraoral direct digital radiographs differ from those revealed on conventional radiographs.  Clinical Implications. Intraoral direct digital radiographs are not an equivalent substitute for conventional radiographs in evaluating alveolar bone levels.