Bitewing and Occlusal radiography .pptx

Bitewing and Occlusal radiography techniques

1. BITEWING AND OCCLUSAL RADIOGRAPHY Presented by OFAMBA JOSHUA 22/U/6772 Date: 22/09/2025 1

2. BITEWING RADIOGRAPHY 2

3.  Introduction Definition and Naming Bitewing radiographs get their name from the original technique where patients bit on a small "wing" attached to an intraoral film packet. Modern techniques use holders, replacing the "wing" with a "tab". Digital image receptors (solid-state or phosphor plate) can now be used instead of film, but terminology and clinical indications remain the same. Image Design An individual image is designed to show the crowns of the premolar and molar teeth on one side of the jaws. 3

4. Main Indications Detection of carious lesions especially interproximal lesions Monitoring the progression of dental caries. Assessment of existing restorations. Assessment of the periodontal status. 4

5. Ideal Technique Requirements An appropriate image receptor holder with a beam-aiming device should be used; The image receptor should be positioned centrally within the holder . The upper and lower edges of the image receptor should be parallel to the bite-platform . The image receptor's long axis should be horizontally for a horizontal bitewing or vertically for a vertical bitewing . The posterior teeth and the image receptor should be in contact or as close together as possible . 5

6. Ideal Technique Requirements cont’d The posterior teeth and the image receptor should be parallel ; two separate image receptor positions may be needed for premolar and molar teeth due to arch shape. The beam-aiming device should ensure that in the horizontal plane , the X-ray tubehead is aimed so the beam meets the teeth and image receptor at right angles , passing directly through all contact areas. 6

7. Ideal Technique Requirements – cont’d The beam-aiming device should ensure that in the vertical plane , the X-ray tubehead is aimed downwards (approximately 5°–8° to the horizontal) to compensate for the upwardly rising curve of Monson. The positioning should be reproducible . Clinicians need to be aware of the original technique (using a tab and aligning the X-ray tubehead by eye) for situations where holders are not possible, particularly in children. 7

8. Two main positioning techniques A. Positioning with Image Receptor Holders B. Positioning with a Tab Attached to the Image Receptor (Traditional Method) 8

9. A. Positioning with Image Receptor Holders 9

10. Image Receptor Holder Components Mechanism for holding the image receptor parallel to the teeth. A bite-platform that replaces the original wing. An X-ray beam-aiming device. 10

11. Image Receptor Holder Technique Steps Select holder and appropriate-sized image receptor (e.g., 31 × 41 mm phosphor plate/film packet or equivalent solid-state sensor). Position patient with head supported and occlusal plane horizontal. Insert holder carefully into the lingual sulcus opposite the posterior teeth. Position anterior edge of image receptor opposite the distal aspect of the lower canine. 11

12. Image Receptor Holder Technique Steps – cont’d Patient closes teeth firmly onto the bite-platform (taking care with solid-state sensor cables). Align X-ray tubehead accurately using the beam-aiming device for optimal horizontal and vertical angulations. Make the exposure . If required, repeat for premolar teeth with a new image receptor and X-ray tubehead position. 12

13. Benefits of using Image Receptor Holders Relatively simple and straightforward . Image receptor is held firmly in position and cannot be displaced by the tongue . Position of X-ray tubehead is determined by the beam-aiming device , assisting the operator in ensuring the X-ray beam is always at right angles to the image receptor. Avoids coning off or cone cutting of the anterior part of the image receptor. Holders are sterilizable or disposable . 13

14. Limitations of using Image Receptor Holders Position of the holder in the mouth is operator-dependent , leading to images not being 100% reproducible and thus not absolutely ideal for monitoring caries progression. Positioning can be uncomfortable for the patient , especially with solid-state digital sensors. Some holders are relatively expensive . Holders are not usually suitable for children . 14

15. B. Positioning with a Tab Attached to the Image Receptor (Traditional Method) 15

16. Tab Technique Suitability Particularly suitable for film packets or digital phosphor plates. Widely used for children, though very operator-dependent( Technique sensitive! ) and not recommended for adults. 16

17. Tab Technique Steps Select appropriate sized image receptor (e.g., large 31 × 41 mm for adults, small 22 × 35 mm for children under 12, or long 53 × 26 mm occasionally for adults) and attach the tab for horizontal or vertical projections. Position patient with head supported and occlusal plane horizontal . Assess dental arch shape and number of films required. Operator holds tab and inserts image receptor into the lingual sulcus opposite posterior teeth. Position anterior edge of image receptor opposite the distal aspect of the lower canine. 17

18. Tab Technique Steps – cont’d Place tab onto the occlusal surfaces of the lower teeth. Patient closes teeth firmly together on the tab. As the patient closes, the operator pulls the tab firmly between the teeth to ensure contact. Operator releases the tab. Operator assesses horizontal and vertical angulations and positions the X-ray tubehead so the beam is aimed directly through contact areas , at right angles to teeth and receptor, with an approx. 5°-8° downward vertical angulation. 18

19. Tab Technique Steps – cont’d Make the exposure. If required, repeat for premolar teeth with a new image receptor and X-ray tubehead position. 19

20. Benefits of Using Tabs Simple. Inexpensive. Tabs are disposable, requiring no extra cross-infection control procedures. Can be used easily in children. 20

21. Limitations of Using Tabs Arbitrary, operator-dependent assessment of horizontal and vertical angulations of the X-ray tubehead . Images are not accurately reproducible, making them not ideal for monitoring caries progression. Coning off or cone cutting of the anterior part of the image receptor is common. Not compatible with using solid-state digital sensors. The tongue can easily displace the image receptor. 21

22. Resultant radiographs Regardless of the technique, the resultant radiographic images and the anatomical structures they show are very similar , though their accuracy varies: 22

23. Typical RIGHT and LEFT horizontal bitewing radiographs of an adult 23

24. Typical RIGHT and LEFT bitewing radiographs of a child 24

25. Image Quality Assessment Essentially involves three separate stages: Comparison of the image against ideal quality criteria . Subjective rating of image quality using published standards. Detailed assessment of rejected films to determine the source of error. 25

26.  Ideal Quality Criteria The image should have acceptable definition with no distortion or blurring. The image should include from the mesial surface of the first premolar to the distal surface of the second molar ; if third molars are erupted, the 7|8 contact should be included. The occlusal plane/bite-platform should be in the middle of the image , showing crowns and coronal parts of maxillary teeth in the upper half and mandibular teeth in the lower half. The buccal and lingual cusps should be superimposed . The image should be free of coning off or cone cutting and other film handling errors. 26

27.  Ideal Quality Criteria – cont’d The maxillary and mandibular alveolar crests should be shown . There should be no overlap of the proximal surfaces of the teeth. Desired density and contrast for film-captured images depend on clinical reasons: For caries and restorations assessment : films should be well exposed with good contrast to differentiate enamel and dentine, and to see the enamel–dentine junction. For periodontal status assessment : films should be underexposed to avoid burn-out of thin alveolar crestal bone. The image should be comparable with previous bitewing images both geometrically and in density and contrast. 27

28. Patient Preparation and Positioning Errors Positioning the image receptor too far posteriorly, failing to image the premolar teeth. Failure to insert the image receptor correctly into the lingual sulcus, allowing the tongue to displace it or causing a non-horizontal occlusal plane. Failure to align the X-ray tubehead correctly in the horizontal plane: Too far posteriorly or anteriorly, causing coning off or cone cutting. Not aimed through contact areas at right angles, causing overlapping of contact areas. Failure to align the X-ray tubehead correctly in the vertical plane, leading to buccal and lingual cusps not superimposed and distortion of teeth. Failure to set correct exposure settings. Failure to instruct the patient to remain still, resulting in blurring due to movement 28

29. A selection of bitewings showing patient preparation and positioning errors. 29 (A) Image receptor positioned too far posteriorly – the edentulous area distal to the lower second is imaged but not the premolar teeth (B) Image receptor displaced by tongue – occlusal plane not horizontal. (C) Failure to align the X-ray tubehead correctly in the horizontal plane – coning off of the anterior part of the image.

30. A selection of bitewings showing patient preparation and positioning errors – cont’d 30 (D) Failure to align the X-ray tubehead correctly in the horizontal plane – overlapping of the contact areas. (E) Failure to align the X-ray tubehead correctly in the vertical plane – buccal and lingual cusps not superimposed and distortion of the teeth. (F) Failure to instruct the patient to remain still – image blurred as a result of movement

31. Patient Preparation and Positioning Errors – cont’d Prevention Note: Many of these positioning errors can be avoided by using image receptor holders with beam-aiming devices . 31

32. OCCLUSAL RADIOGRAPHY TECHNIQUES 32

33.  Introduction Definition Intraoral radiographic techniques using a dental X-ray set where the image receptor is placed in the occlusal plane . Image Receptor Uses digital phosphor plates or film packets (5.7 × 7.6 cm). Suitable-sized solid-state digital sensors are not currently available . 33

34. Terminology and Classification Note: Terminology is often confusing; the preferred terms aim to be explicit and practical. Classification: A. Maxillary Occlusal Projections Upper standard (or anterior) occlusal. Upper oblique occlusal. B. Mandibular Occlusal Projections Lower 90° (or true) occlusal. Lower 45° (or anterior) occlusal. Lower oblique occlusal. 34

35. A. Maxillary Occlusal Projections 35

36. 1. Upper standard(or anterior) occlusal projection Projection Focus Shows the anterior part of the maxilla and the upper anterior teeth. Main Clinical Indications Periapical assessment of upper anterior teeth (especially in children, or adults unable to tolerate periapical holders). Detecting unerupted canines, supernumeraries, and odontomes . As the midline view for the parallax method (determining bucco /palatal position of unerupted canines). Evaluation of the size and extent of lesions (cysts or tumours ) in the anterior maxilla. Assessment of fractures of the anterior teeth and alveolar bone. 36

37. Upper Anterior occlusal projection technique and positioning steps Patient seated with head supported, occlusal plane horizontal and parallel to the floor; patient asked to support a protective thyroid shield. Image receptor (barrier-wrapped) placed flat into the mouth onto the occlusal surfaces of the lower teeth, centrally, with its long axis anteroposteriorly ; patient bites gently. X-ray tubehead positioned above the patient in the midline, aiming downwards through the bridge of the nose at an angle of 65–70° to the image receptor. 37

38. Resultant radiograph 38

39. 2. Upper Oblique Occlusal Projection Projection Focus Shows the posterior part of the maxilla and the upper posterior teeth on one side . Main Clinical Indications Periapical assessment of upper posterior teeth (especially in adults unable to tolerate periapical holders). Evaluation of the size and extent of lesions (cysts, tumours , or other bone lesions) affecting the posterior maxilla. Assessment of the condition of the antral floor . Aid in determining the position of roots displaced inadvertently into the antrum during attempted extraction of upper posterior teeth. Assessment of fractures of the posterior teeth and associated alveolar bone, including the tuberosity. 39

40. Upper Oblique Occlusal projection technique and positioning steps Patient seated with head supported and occlusal plane horizontal and parallel to the floor. Image receptor (barrier-wrapped) inserted into the mouth onto the occlusal surfaces of the lower teeth, with its long axis anteroposteriorly , placed to the side of the mouth under investigation; patient bites gently. X-ray tubehead positioned to the side of the patient’s face, aiming downwards through the cheek at an angle of 65°–70° to the image receptor, centring on the region of interest. 40

41. Resultant radiograph 41

42. B. Mandibular Occlusal Projections 42

43. 1. Lower 90° (or True) Occlusal Projection Projection Focus Shows a plan view of the tooth-bearing portion of the mandible and the floor of the mouth . A minor variation can show unilateral lesions. Main Clinical Indications Detection of the presence and position of radiopaque calculi in the submandibular salivary ducts. Assessment of the buccolingual position of unerupted mandibular teeth . Assessment of fracture displacement of the anterior mandible in the horizontal plane. Evaluation of the buccolingual expansion of the body of the mandible by cysts/ tumours . Assessment of mandibular width prior to implant placement. 43

44. Lower 90° (or True) Occlusal Projection Technique and Positioning Steps Image receptor (barrier-wrapped, facing downwards) placed centrally into the mouth, onto the occlusal surfaces of the lower teeth, with its long axis anteroposteriorly ; patient bites gently. Patient leans forwards and then tips the head backwards as far as comfortable, where it is supported. X-ray tubehead (with circular collimator) placed below the patient’s chin, in the midline, centring on an imaginary line joining the first molars, at an angle of 90° to the image receptor. 44

45. Resultant radiograph 45

46. 2. Lower 45° (or Anterior) Occlusal Projection Projection Focus Shows the lower anterior teeth and the anterior part of the mandible . Resembles a large bisected angle technique periapical of this region. Main Clinical Indications Periapical assessment of the lower incisor teeth (especially useful in adults and children unable to tolerate periapical holders). Evaluation of the size and extent of lesions (cysts or tumours ) affecting the anterior part of the mandible. Assessment of fracture displacement of the anterior mandible in the vertical plane. 46

47. Lower 45° (or Anterior) Occlusal Technique and Positioning Steps Patient seated with head supported and occlusal plane horizontal and parallel to the floor. Image receptor (barrier-wrapped, facing downwards) placed centrally into the mouth, onto the occlusal surfaces of the lower teeth, with its long axis anteroposteriorly ; patient bites gently. X-ray tubehead positioned in the midline, centring through the chin point, at an angle of 45° to the image receptor. 47

48. Resultant radiograph 48

49. 3. Lower Oblique Occlusal Projection Projection Focus Designed to allow the image of the submandibular salivary gland on the side of interest to be projected onto the image receptor. All anatomical tissues shown are distorted due to the oblique X-ray beam. Main Clinical Indications Detection of radiopaque calculi in the submandibular salivary gland of interest. Assessment of the buccolingual position of unerupted lower wisdom teeth . Evaluation of the extent and expansion of cysts, tumours , or other bone lesions in the posterior part of the body and angle of the mandible. 49

50. Lower Oblique Occlusal Projection Technique and Positioning steps Image receptor (barrier-wrapped, facing downwards) inserted into the mouth, onto the occlusal surfaces of the lower teeth, over to the side under investigation, with its long axis anteroposteriorly ; patient bites gently. Patient’s head supported , then rotated away from the side under investigation and the chin raised (to allow X-ray tubehead positioning). X-ray tubehead (with circular collimator) aimed upwards and forwards towards the image receptor, from below and behind the angle of the mandible and parallel to the lingual surface of the mandible. 50

51. Resultant radiograph 51

52. Occlusal Radiograph Anatomy 52

53. Upper Standard Occlusal radiographs 53

54. Lower Occlusal radiographs 54

55. References Whaites , Eric, and Nicholas Drage . Essentials of Dental Radiography and Radiology . 6th ed. London: Elsevier, 2020 Mallya , Sanjay M., and Ernest W. N. Lam.  White and Pharaoh's Oral Radiology: Principles and Interpretation . 8th ed. Elsevier - Health Sciences Division; Mosby, 2018. Ferreira Zandona A, Longbottom C (eds) (2019) Conventional bitewing radiographs detection and assessment of dental caries . Springer, Berlin. https://doi.org/10.1007/978-3-030-16967-1_11 Occlusal Radiography | Clinical gate. https://clinicalgate.com/occlusal-radiography/ 55