Introduction

From the earliest days of dental radiography a clinical objective has been to produce accurate images of dental structures that are normally visually obscured. An early method for aligning the x-ray beam and film with the teeth and jaws was the bisecting-angle technique.

Bisecting Angle Technique

Cieszynski Rule of Isometry - That two triangles are equal when they share one complete side and have two equal angles. - Dental radiography applies the theorem as follows: Position the film as close as possible to the lingual surface of the teeth, resting in the palate or in the floor of the mouth. - The plane of the film and the long axis of the teeth form an angle with its apex at the point where the film is in contact with the teeth. - Construct an imaginary line that bisects this angle and direct the central ray of the beam at right angles to this bisector. - This forms two triangles with two equal angles and a common side (the imaginary bisector). - Consequently, when these conditions are satisfied, the images cast on the film theoretically are the same length as the projected object.

Film-Holding Instruments The preferred method is to use a film-holding instrument (e.g. the Snap-A-Ray) or bisecting-angle instrument. Both provide an external device for localizing the x-ray beam. The bisecting angle instrument uses a fixed average bisecting angle. The method most often used is to have the patient support the film from the lingual surface with his or her forefinger. However, this method has several drawbacks. o Patients often use excessive force and bend the film, causing distortion of the image o The film might slip without the operator's expertise, resulting in an improper image field. o Without an external guide to the position of the film,the x-ray beam may miss part of the film, resulting in a partial image (cone cut).

Positioning of the Patient To radiograph the maxillary arch, the patient's head should be positioned upright with the sagittal plane vertical and the occlusal plane horizontal.

When the mandibular teeth are to be radiographed, the head is tilted back slightly to compensate for the changed occlusal plane when the mouth is opened.

Film Placement Film is positioned behind the areas of interest, with the apical end against the mucosa on the lingual or palatal surface. The occlusal or incisal edge is oriented against the teeth with an edge of the film extending just beyond the teeth. For the patients comfort, the anterior corner of the film can be softened by bending it before it is placed against the mucosa. Care should be taken not to bend the film excessively because this may be result in image distortion & pressure defects in the emulsion.

Angulation of the Tube Head Horizontal angulation. - When a film-holding device with a beam-localizing ring is used, the instrument is positioned horizontally so that when the tube is aligned with the ring, the central ray is directed through the contacts in the region being examined. - If the filmholding device does not have a beam-localizing feature, the tube is pointed so as to direct the central ray through the contacts. - In this situation the radiation beam is also centered on the film. - This angulation usually is at right angles (in the horizontal projection) to the buccal or facial surfaces of the teeth in each region. Vertical angulation. - The central ray of the x-ray beam should be at right angles to a plane bisecting the angle between the film and the long axis of the tooth. - This principle works well with flat, two-dimensional structures, but teeth that have depth or are multirooted show evidence of istortion. - Excessive vertical angulation results in foreshortening of the image, whereas insufficient vertical angulation results in image elongation

Advantages of the bisecting 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 may result if the central ray is not aimed at the centre of the film, particularly if using rectangular collimation. 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 proximal caries. The buccal roots of the maxillary premolars and molars are foreshortened.

Paralleling Technique
Also called:- Right Angle technique - Long Cone Technique The central concept of the paralleling technique is that the x-ray film is supported parallel to the long axis of the teeth and the central ray of the x-ray beam is directed at right angles to the teeth and film. - This orientation of the film, teeth, and central ray minimizes geometric distortion and presents the teeth and supporting bone in their true anatomic relationship. - To reduce geometric distortion further, the x-ray source should be located relatively distant from the teeth. - The use of a long source-to-object distance reduces the apparent size of the focal spot, thus increasing image sharpness and provides images with minimal magnification. - These factors result in images with less magnification and increased definition.

Film-Holding Instruments - Film-holding instruments are used to position the film properly in the patient's mouth and maintain the film in position. - To position the film parallel to the teeth and project the periapical areas onto the film, the film is positioned away from the teeth and toward the center of the mouth to use the maximal height of the palate. - The long source-to-object distance used in the paralleling technique minimizes the disadvantages imposed by the increased object-to-film distance. - For maxillary projections, the superior border of the film generally rests at the height of the palatal vault in the midline. - For mandibular projections, the film is used to displace the tongue toward the midline to allow the inferior border of the film to rest on the floor of the mouth away from the mucosa on the lingual surface of the mandible. - A number of available commercial devices can hold the film parallel and at varying distances from the teeth are recommended because they significantly reduce patient exposure by limiting the field of exposure to the size of the film. o The Precision instrument (Masel, Bristol, PA)

o XCP instrument used with a rectangular aiming device (Rinn Corp., Elgin, IL)

Angulation of the Tube Head Orientation of the x ray machines aiming cylinder in the vertical & horizontal planes should be adjusted to align with the aiming ring. 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. The periapical tissues are accurately shown with minimal foreshortening or elongation. The crowns of the teeth are well shown enabling the detection of approximal 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. The relative positions of the film packet, teeth and X-ray beam are always maintained, irrespective of the position of the patient's head. This is useful for some patients with disabilities. 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 because of the resultant magnification.