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Periapical radiography

Periapical radiography describes intraoral techniques designed to show individual teeth and the tissues around the apices. Each film usually shows two to four teeth and provides detailed information about the teeth and the surrounding alveolar bone.

Main indications
The main clinical indications for periapical radiography include:

Detection of apical infection/inflammation Assessment of the periodontal status After trauma to the teeth and associated Assessment of the presence and position of 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. unerupted teeth alveolar bone
Fig. 8.1 Diagram illustrating the ideal geometrical relationship between film, tooth and X-ray beam.

The film packet should be positioned with its

long axis vertically for incisors and canines, and horizontally for premolars and molars with sufficient film beyond the apices to record the apical tissues The X-ray tubehead should be positioned so that the beam meets the tooth and the film at right angles in both the vertical and the horizontal planes The positioning should be reproducible.

Ideal positioning requirements

The ideal requirements for the position of the film packet and the X-ray beam, relative to a tooth, are shown in Figure 8.1. They include:

Radiographic techniques
The anatomy of the oral cavity does not always allow all these ideal positioning requirements to be satisfied. In an attempt to overcome the problems, two techniques for periapical radiography have been developed:

The tooth under investigation and the film

packet should be in contact or, if not feasible, as close together as possible The tooth and the film packet should be parallel to one another

The paralleling technique The bisected angle technique.

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Paralleling technique
Theory 1. The film packet is placed in a holder and positioned in the mouth parallel to the long axis of the tooth under investigation. 2. The X-ray tubehead is then aimed at right angles (vertically and horizontally) to both the tooth and the film packet. 3. By using a film holder with fixed film packet and X-ray tubehead positions, the technique is reproducible. This positioning has the potential to satisfy four of the five ideal requirements mentioned earlier.

However, the anatomy of the palate and the shape of the arches mean that the tooth and the film packet cannot be both parallel and in contact. As shown in Figure 8.2, the film packet has to be positioned some distance from the tooth. To prevent the magnification of the image that this separation would cause, a parallel, nondiverging, X-ray beam is required (see Fig. 8.3). As explained in Chapter 5, this is achieved usually by having a large focal spot to skin distance, by having a long spacer cone or beam-indicating device (BID) on the X-ray set. Film packet holders A variety of holders has been developed for this technique. The choice of holder is a matter of personal preference the Rinn XCP holders, shown in Figure 8.4, being favoured by the author. The different holders vary in cost and design but essentially consist of three basic components:

A mechanism for holding the film packet

parallel to the teeth that also prevents bending of the packet A bite block or platform An X-ray beam-aiming device. This may or may not provide additional collimation of the beam.

Positioning techniques
Fig. 8.2 Diagram showing the position the film packet has to occupy in the mouth to be parallel to the long axis of the tooth, because of the slope of the palate.

The radiographic techniques for the permanent dentition can be summarized as follows:

Fig. 8.3 Diagrams showing the magnification of the image that results from using A a short cone and a diverging X-ray beam and B a long cone and a near-parallel X-ray beam.

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Periapical radiography

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D A

B (i) (ii)

Fig. 8.4 (i) A selection of film packet holders designed for the paralleling technique. A HaweNeos Superbite posterior holder (colour coded red). B HaweNeos Superbite anterior holder (colour coded green). C Rinn XCP posterior holder (colour coded yellow). D Rinn XCP anterior holder (colour coded blue) with film packet inserted. E Unibite posterior holder. (ii) Rectangular collimation provided by A the Masel Precision all-in-one metal holder and B the Rinn XCP holder with its additional metal collimator attached to the white locator ring.

1. The appropriate holder and size of film packet are selected. For incisors and canines (maxillary and mandibular) an anterior holder should be used and a small film packet (22 35 mm) with its long axis vertical. For premolars and molars (maxillary and mandibular) use a posterior holder (right or left as required) and a large film packet (31 41 mm) with its long axis horizontal, in addition: a. The smooth, white surface of the film packet must face towards the X-ray tubehead. b. The end of the film packet with the embossed orientation dot is placed opposite the crowns of the teeth (to avoid subsequent superimposition of the dot over an apex). 2. The patient is positioned with the head supported and with the occlusal plane horizontal. 3. The holder and film packet are placed in the mouth as follows: a. Maxillary incisors and canines the film packet is positioned sufficiently posteriorly to enable its height to be accommodated in the vault of the palate b. Mandibular incisors and canines the film packet is positioned in the floor of the

mouth, approximately in line with the lower canines or first premolars c. Maxillary premolars and molars the film packet is placed in the midline of the palate, again to accommodate its height in the vault of the palate d. Mandibular premolars and molars the film packet is placed in the lingual sulcus next to the appropriate teeth. 4. The holder is rotated so that the teeth under investigation are touching the bite block. 5. A cottonwool roll is placed on the reverse side of the bite block. This often helps to keep the tooth and film packet parallel and may make the holder less uncomfortable. 6. The patient is requested to bite gently together, to stabilize the holder in position. 7. The locator ring is moved down the indicator rod until it is just in contact with the patients face. This ensures the correct focal spot to film distance. 8. 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. 9. The exposure is made (see Figs 8.58.12).

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Maxillary incisors

D Fig. 8.5A Patient positioning (Maxillary central incisor). B Diagram of the positioning. C Plan view of the positioning. D Resultant radiograph with the main radiographic features indicated.