Bitewing Technique

The following slides describe techniques

used in taking bitewing films.

In navigating through the slides, you should click

on the left mouse button when you see the
mouse holding an x-ray tubehead or you are
done reading a slide. Hitting “Enter” or “Page
Down” will also work. To go back to the previous
slide, hit “backspace” or “page up”.
 Patient Preparation
Prior to starting to take films, the patient must
be positioned properly. Seat the patient and ask
them to remove their glasses and any removable
partial dentures or orthodontic appliances.
Adjust the headrest to support the head while
taking films. Raise or lower the chair to a
comfortable height for the operator. Place the
lead apron and thyroid collar on the patient. You
are now ready to begin taking films.

It is a good idea to inform the patient about the

number of films you will be taking so they know
what to expect, especially when doing a full-
mouth series.
Bitewing Technique
 Bitewing Film

This film gets its name from the tab (“wing”) that
the patient bites on to hold the film in place. The
bitewing film is used for the detection of
interproximal caries and the condition of the
alveolar bone. This film shows the crowns of
both the maxillary and mandibular teeth and a
portion of the roots.

A premolar film and molar film are normally

taken on each side for a total of four posterior
bitewing films.
 Head Position
The head is normally positioned so that the
maxillary arch is parallel to the floor and the
midsagittal plane (MSP) is perpendicular to the floor.
This is a definite requirement when using bitewing
tabs to hold the film in position; it is not as
important when using the Rinn Bitewing Instrument.
MSP

head supported by headrest

 Bitewing Film Placement
Tabs
The traditional method of bitewing placement uses tabs.
The tab in the photo below left is attached to a sleeve
through which the film is inserted. The disadvantage to
this type of tab is that the film can move forward or
backward as the patient closes. The preferred type of
tab, below right, sticks to the white side of the film and
does not allow the film to move during closure.
 Bitewing Film Placement
Bitewing Instrument
The Rinn Bitewing Instrument pictured below is
frequently used instead of tabs. The instrument
facilitates placement and the ring insures correct
alignment of the PID.
 Rinn Bitewing Instrument
Instrument set-up

The prongs on the bar are aligned with the

holes in the biteblock and the two are attached.
The ring is placed on the bar so that it is
centered on the biteblock.
 Rinn Bitewing Instrument

Before placing the film in the biteblock, the

film should be bent gently around a finger
(white side down, long axis in line with
finger).
 Rinn Bitewing Instrument

Place the film, white side facing ring, under one

tab, centered front to back, and then gently
place the opposite edge of the film under the
other tab. The film may curve slightly away from
the ring. The location of the identifying dot on
the film is not important.
 Rinn Bitewing Instrument

Make sure the all-white side of the film is visible

through the ring (White-in-sight). You are now
ready to place the film in the mouth. This set-up
works for both sides of the mouth (Instrument
does not need to be changed).
 Bitewing Technique
Film Position
(Same for tabs or Rinn BW instrument)
The premolar bitewing film is approximately centered
on the 2nd premolar; the front edge of the film should
be at least in the middle of the canine. The molar film
is centered on the 2nd molar if the third molars are
present. The long axis of the film is horizontal.
The position of the film dot doesn’t matter; it will be
beyond the crowns of the teeth on the film.

long axis

premolar molar (3rds)

 Bitewing Technique
Film Position
If the third molars are not erupted into the mouth, it is
not necessary to position the film to cover the third
molar region. It is better to move the film slightly
forward, centered on the contact between the first and
second molars. This gives you duplicate information in
the second premolar/first molar areas, which may aide
in making a diagnosis in these areas.

molar (no 3rds)

 Bitewing Technique
Film Placement
It is important to always start with the premolar
bitewing. This allows apprehensive patients or those
with active gag reflexes to somewhat get used to the
film before proceeding to the more posterior molar
film. Both films on one side should normally be
completed before moving to the other side.
However, if a patient has problems with gagging on
the premolar film, I recommend immediately going
to the other side and taking the premolar film. Once
the two premolar films are taken, you can attempt to
take the molar films.
Vertical Angulation (with tabs)
When the film is positioned in the mouth, the upper
portion of the film is angled approximately +20° as
it contacts the palate. In the mandible, the film is
upright (0° angle). The average between these two
angles is +10°. This +10° is the vertical angulation
selected when using bitewing tabs.

+20º

0º
 Vertical Angulation (with tabs)
Adjust tubehead so that the 10° mark is opposite the
position guide. The 10° setting may be above or below
the zero mark, depending on which way the tubehead
is rotated around the supporting yoke (see photos
middle and right below). The PID must be angled
downward for all positive angulations; if it is angled
upward it is a negative angulation.

10°

position guide
Make sure the maxillary arch is parallel to the floor and
the midsagittal plane is perpendicular to the floor
before aligning the tubehead. In the photo below left
the PID is angled downward at 10 degrees as
recommended, but the patient’s head is tipped to the
side. Rotating this same picture (below right) to
position the maxillary arch parallel to the floor (dotted
line) shows that the true angle of the PID is upward in
relation to the film. This will give a distorted image.

+10°
Vertical Angulation (with instrument)

When using the Rinn BW instrument, align the

PID with the ring. This automatically aligns the
x-ray beam with the correct vertical angulation,
no matter how the head is positioned.
 Horizontal Angulation (with tabs)
The horizontal angulation is adjusted so that a line
connecting the front and back edge of the PID (yellow
line below) is parallel with a line connecting the buccal
surfaces of the premolars and molars (green line below).
The x-rays will then pass straight through the contact
areas between the teeth. The front edge of the PID
should be ¼” anterior to the front edge of the film to
keep the beam centered on the film.

correct incorrect
Horizontal Angulation (with instrument)

When using the Rinn BW instrument, align the

PID with the ring. This automatically aligns the x-
ray beam with the correct horizontal angulation,
assuming the film was positioned properly in the
mouth. (See following slide).
The film should be equidistant from the teeth in an
anterior-posterior direction (the distance from the front
edge of the film to the lingual surface of the teeth
should be the same as the distance from the back edge
of the film to the lingual surface of the teeth). The film
should be positioned in this manner for both the
premolar and molar radiographs. This helps to avoid
overlap (see “Errors”).

correct incorrect incorrect

When aligning the PID, have the patient “smile big” with
their teeth together; this allows you to see the buccal
surface of the posterior teeth when using tabs. When
using the Rinn instrument, this helps you make sure the
patient is biting completely, not just tightening their lips
around the instrument. The center of the x-ray beam
(dotted line) should be directed at the occlusal plane;
this centers the beam top to bottom.
Where teeth are missing, it is often necessary to use
a cotton roll to help support the tab or instrument.
Position the film in the mouth and then slide the
cotton roll into the edentulous area. Make sure the
cotton roll does not rest on top of the occlusal
surface of the teeth that are present.

cotton roll
In the film at left, a cotton roll
was not used and the tab and
film dropped down into the
edentulous area, resulting in a
tipped film.

In the film at left, a cotton roll

was used, keeping the tab and
long axis of the film parallel
with the occlusal plane.
Another thing to consider when there are edentulous
areas is to position the bitewing tab forward or
backward on the film so that the tab comes in maximum
contact with the teeth that are present. In the premolar
placement below, the tab was moved forward for
maximum contact with the mandibular premolars. For
the molar film, the tab would be moved toward the back
end of the film to contact the 2nd molar.
The film may be angled in the mouth to
facilitate anterior placement when using
the tabs. As long as the horizontal
angulation is aligned properly, the teeth
will not be overlapped.

When using tabs, make sure the

film clears the palatal gingiva as
the patient closes to keep the
film from being pushed down
into the mandible.
If lingual tori are present, the film must be placed
lingual to the torus (both with tabs and the instrument).
When using tabs, it is often helpful to attach another
tab to the one attached to the film; this lengthens the
portion you hold on to, making it easier to position the
film more toward the tongue and lingual to the torus.

film
torus

extra tab
extra length

tab on film
 Bitewing Films

Premolar Bitewing: covers Molar Bitewing: covers

both premolars, first molars. In this patient,
molars and at least a with no third molars, the
portion of second molars. film was positioned too
far posteriorly.
 Bitewing Films

If third molars are not erupted into the mouth, the

molar film should be positioned more anteriorly, as
seen above. Make sure ¼” of film extends posterior
to second molar so that the distal aspect of both
upper and lower second molars, including the bone,
can be seen.
 Bitewing Films

In some patients, one film may cover all posterior

teeth if the third molars are not present. This can
often be determined during film placement or by
looking at previous films. If you’re not sure, take
both premolar and molar films.
 Bitewing Films

If the first premolars are missing (often seen

with orthodontic patients) and the third
molars are not present, one bitewing per
side is enough.
 Bitewing Films

If it is determined that bitewing films are needed

on a patient that is completely edentulous in one
arch, a complete denture may be left in the
mouth to help support the bitewing tab or
bitewing instrument. The maxillary complete
denture is used in the film above.
 Vertical Bitewing
For the routine bitewing film, the long axis of the film
is horizontal (side-to-side). In patients with advanced
periodontal involvement, the bone loss may be so
extensive that it does not show up on the normal
bitewing. For these patients, some dentists prefer to
have the bitewing film positioned with the long axis
placed vertically (up-and-down). This is called a
vertical bitewing.
long axis
 Vertical Bitewing
Two bitewings (premolar and molar) are normally taken
on each side posteriorly, just as with regular bitewings,
for a total of four posterior films.

If indicated, vertical bitewings can also be taken in the

anterior region. A total of three anterior films would be
used: one centered on the midline to show the incisors
and one on each side to image the canine regions.

right right right incisor left left left

molar premolar canine canine premolar molar
 Vertical Bitewing
Vertical bitewing films can be taken using tabs or
a bitewing instrument, just as with regular
bitewings.

The vertical angulation is +10° with tabs; the PID

is aligned with the ring when using the
instrument.

The horizontal angulation is determined in the

same manner as it is with regular bitewings. The
object is to open the contacts between the teeth
on the film.
 Bitewing Technique Errors

The following slides identify some of the most

common errors seen when using the bitewing
technique.
 Overlap
If the horizontal angulation is not aligned correctly, so
that the x-rays pass through the teeth contacts at an
angle, the contact areas will be overlapped (see arrows
on film below).
Overlap is the superimposition of part of one tooth
with part of the adjacent tooth (dotted circles below
left). The red arrow represents the direction of the x-
ray beam; the x-ray beam should be perpendicular to
the dotted line below. (See discussion of horizontal
angulation on earlier slide).
 Overlap
Sometimes overlap is unavoidable due to the
malposition of some teeth. One or more teeth may be
more buccal or lingual than the adjacent teeth,
resulting in crowding and changing the angle of
contact between these teeth. The arrow in the film
below points to an example of this type of overlap.
If the majority of contacts are open on a film, with
only a few areas overlapped, this would not be
considered an error.
 Improper Film Placement
Improper film placement is a common error
seen in the bitewing technique. In the premolar
film below left, the film was placed too far back,
cutting off the mesial of the first premolar. In the
molar bitewing, below right, the film was not
back far enough, cutting off the distal aspect of
the third molars.
 Improper Film Placement
If the top edge of the film contacts the palatal
gingival ledge, the film may be pushed down into
the floor of the mouth as the patient closes. This
results in a bitewing that looks more like a
periapical film, as seen in the two films below.
This is more likely to happen when using tabs.
 Cone Cutting
If the x-ray tubehead is not positioned properly, the x-ray
beam may not cover the entire film. This is known as
conecutting, which results in a clear (white) area on the
film where the silver halide crystals were not exposed to
x-rays (see films below). In the diagram below right, the
dotted circle represents where the x-ray beam should
have been positioned; the solid circle shows the actual
position of the x-ray beam (too posterior).
 Patient Movement
If the patient moves or opens the mouth slightly
during exposure, a blurred or distorted image
may result. The film below was produced when
the patient opened the mouth partway through
the exposure. It looks similar to a double
exposure.
 Reversed Film
If the tab is placed on the colored side of the film
or the film is placed in the bitewing instrument with
the colored portion facing the ring, the lead foil in
the film packet will be between the teeth and the
film. This results in the pattern stamped on the
lead foil appearing on the film (see small dark
squares on right side of film below). The film will
also be lighter than the other films taken at the
same time.
 Unnecessary Films
The patient below has no second or third molars
on the right side. The premolar film is all that is
needed on this patient. The patient received
uneccessary exposure by taking the molar film.

M PM
 Unnecessary Films
This patient had a complete upper denture and a
lower partial denture which replace all the
molars on the left side. This film showing only
denture teeth should obviously not have been
taken.
 Full Mouth Series
The paralleling and bisecting angle techniques are
used to take periapical films and have nothing to do
with the bitewing technique. When taking a full mouth
series on a patient with a full compliment of teeth, four
bitewing films are normally taken. These are
combined with 15 periapicals (# 1 films used
anteriorly) when using the paralleling technique or 14
periapicals (# 2 films used anteriorly) when using the
bisecting angle technique.

Paralleling full mouth series of periapicals + 4

bitewings = 19 films
Bisecting angle full mouth series of periapicals + 4
bitewings = 18 films
This concludes the section on Bitewing
Technique.

Additional self-study modules are available

at: http://dent.osu.edu/radiology/resources.php

If you have any questions, you may e-mail

me at jaynes.1@osu.edu.

Robert M. Jaynes, DDS, MS

Director, Radiology Group
College of Dentistry
Ohio State University