Beruflich Dokumente
Kultur Dokumente
Presented at the 1971 meeting of the Oral Radiology Section of the American Associa-
tion of Dental Schools, Chicago, Ill.
*Associate Professor, Division of Oral Radiology; Active Member of the American
Academy of Dental Radrology.
**Assistant Professor, Division of Oral Radiology.
284
Volume 33 Comparison of radiographic techniques 285
Number 2
taining the same good results from the average student in a learning situation.
The objective of this study was to determine the merits and effects of two
different instruments (the Xtension Cone Paralleling instrument (XCP) * and
the Precision x-ray instrumentt ) in the teaching of the paralleling technique.
with the students the technical errors shown in the radiographs taken in the
previous session and explained how these errors could be corrected or avoided.
In addition, instructors were available in the clinic to supervise the training
of the students. Special assistance was given when requested by a student in
case of difficulty encountered in some technical procedure.
The number of periapical radiographic surveys made by the students is
shown in Table I. A total of 585 periapical surveys were made exclusively by
junior and senior students on regu1a.r clinic patients. Students using the Snap-
A-Ray film holder made 198 surveys, those using the XCP instrument made 214
surveys, and students using the Precision instrument made 173 surveys.
The average number of surveys made by a student was 3.7 when the Snap-
A-Ray film holder was used, 4 when the XCP instrument was used, and 3.4
when the Precision x-ray instrument was used. Variations in the number of sur-
veys performed by a student were due mostly to variations in patient avail-
ability.
Periapical surveys for adult, dentulous patients were used and consisted of
fourteen standard-sized films (No. 2) when the Snap-A-Ray film holder was
used. Sixteen films were used with either of the paralleling instruments; stan-
dard-sized films (No. 2) were used for examining premolar-molar areas, and
No. 1 films were used for examining anterior teeth. The two additional films
were used in examining the maxillary lateral incisors.
The total number of periapical films taken for this study was 3,726. Ttvo
hundred thirty-eight films (2.6 per cent) were missing at time of film evaluation.
A total of 2,721 films were ta.ken by the Snap-A-Ray film holder group (51 films
were missing) ; 3,330 were taken by the XCP group (94 films were missing), and
2,675 films were taken with the Precision instrument (93 films were missing).
Three different brands of x-ray unit were used. One machine had an ex-
ternally short built-in “long cone” (an open-ended opaque lead-lined cone) ,*
another was equipped with a long open-ended opaque lead-lined cone,t and the
third machine had a long open-ended transparent plastic cone-$ The beam di-
ameter at the cone tips of the x-ray units was 2.75 inches except for the built-in
“long cone,” which had a beam diameter of 2.5 inches.
Errors counted in this study were technical errors made by the students.
Errors due to incorrect x-ray exposure or improper film processing were not
Ii 125
29 Ki :i 1.2
0.9 16
25 1.8
1.1
T 736 51.2 679 42.2 648 46.2
Seniors
F 232
143 18.1
11.1 414 24.0 302
30 23.7
2.4
H 86 6.7 2:: 1i.i 97 7.6
H” 217
321 11.8
8.0 404
38 12.2
1.1 205
71 7.7
2.6
iz 279 10.2
1.4 :8” 1.0 37
19 1.4
0.7
T 1,3% 49.9 1,365 4::: 1,092 40.8
P = Improper film positioning.
V = Incorrect vertical angulation.
H = Horizontal overlap.
C = Cone-cutting.
M = Miscellaneous errors.
T = Total.
Technical faults made by junior students were similar t,o those made by
senior students, with minor exceptions. The junior students demonstrated al-
most equal distribution of cone-cutting (8.7 per cent) and horizontal overlap
(9.1 per cent), while the senior students showed more cone-cutting (12 per cent)
and less horizontal overlap (6.7 per cent).
Regional distribution of the technical errors is shown in Fig. 1. It was noted
that improper film positioning occurred with higher frequency in the premolar-
molar regions of both jaws but to a lesser degree in the maxillary premolar-
molar regions. Horizontal overlap was noted most often in relation to the maxil-
lary cuspid area. Incorrect vertical angulation was more frequently noted in
the maxillary premolar-molar areas and the cuspid areas of both jaws. Cone-
cutting was seen most often in the molar areas and, to a lesser degree, in the
premolar areas in both jaws. The students made 7.8 per cent more technical
errors in the films taken in the maxilla than in those taken in the mandible.
When the junior and senior students used the Snap-A-Ray film holder with
the bisecting-angle technique, their performance was nearly equal in the type
Volume 33 Comparison of radiographic techniques 289
Number 2
Fig. 8’. Distribution of periapieal radiographic errors made by 158 junior and senior dental
students.
and number of radiographic errors. Improper film positioning was the most fre-
quent error. All other errors occurred with nearly equal frequency (Fig. 2).
The performance of students using the bisecting-angle technique is almost
identical to the performance seen in another study and with a similar pattern
of radiographic err0rs.l This finding may be indicative of an inherent short-
coming in the bisecting-angle technique.
Students using the XCP instrument demonstrated a drastic reduction in
both cone-cutting and vertical angulation errors. The occurrence of these two
errors was 1 per cent and 1.1 per cent, respectively (Table II). The performance
of junior students closely paralleled that of senior students. However, there was
a significant increase in errors caused by improper film positioning (25.6 per
cent), and horizontal overlap was more frequent (12.2 per cent) than when the
Snap-A-Ray film holder was used. Both the junior and senior students experi-
enced equal degrees of difficulty in film positioning as well as in the frequency
of horizontal overlapping (Table II).
When the ra,diographs were evaluated individually, the frequency of errors
was 41 per cent with the XCP instrument. Senior students showed a 2.4 per cent
improvement over junior students (Table II). In contrast, senior students using
the Snap-A-Ray film holder did not show much improvement over juniors (2.7
per cent difference only), although each senior student had made, on the aver-
age, eight to ten periapical surveys the previous year.
Regional distribution of errors made by the junior and senior students who
Fiy. 8. R,egional distrikmtion of 1,365 periapic’al radiographic errors madr- by 53 junior and
senior dental students in 214 periapical surveys when the students uwd thcx XCI’ instrument.
used the XCP instrument is shown in &‘ig. 3 .* Most of the improper film posi-
tioning occurred, in descending frequency, in the molar areas, the maxillary
central incisor area, and the premolar areas. The difficulty faced by students
using the XCP instrument in the positioning of films might be attributed to
the fact that the XCP instrument, in comparison to the Snap-A-Ray film holder,
is somewhat more voluminous. Film-positioning difficulty increased when the
students were confronted with the far distal loca.tion of the molars and with
interference by the floor of the mouth and/or the tongue during premolar-molar
film positioning. Improper film positioning in the maxillary central incisor area
was caused by the failure of some students to put the film in a central position
in relation to the cenOra1 incisor teeth. The narrow films used (Size 1) may have
contributed to the frequency of this error.
It was noted that most of the horizontal overlapping associated with the use
of the XCP instrument occurred in the maxillary cuspid areas and, to a far
lesser degree, the maxillary premolar areas (Fig. 3). This suggests that employ-
ment of the XCP instrument, as with the Snap-A-Ray film holder, is associated
with a high frequency of overlapping in the maxillary cuspid regions (44.6 per
*Since cone-cutting and incorrect vertical angulation errors were minimal when the XCP
instrument was used, both of these errors were added to the category of miscellaneous errors.
Volume 33 Comparison of radiographic techniques 291
Number 2
cent and 33.7 per cent, respectively). Over-all, 13 per cent more errors were
made in films taken in the maxilla than in those taken in the mandible when
the XCP instrument was used.
Although students using the XCP instrument showed more improper film
positioning and horizontal overlapping than students using the Snap-A-Ray film
holder, there was a 9 per cent over-all improvement of films made with the XCP
instrument over those made with the Snap-A-Ray film holder (Fig. 2). In our
opinion, the two problems of improper film positioning and horizontal overlap-
ping constitute a challenge for both teachers and students when the XCP in-
strument is used as the method of choice. Hopefully, the frequency of these two
errors can be reduced to a more acceptable level.
The students who used the Precision x-ray instrument also demonstrated a
substantial reduction in cone-cutting and incorrect vertical angulation errors
(Table II) when their films were compared to films made with the Snap-A-Ray.
The occurrence of these two errors was 0.7 per cent and 2.6 per cent, respec-
tively. These data are comparable with those seen when the XCP instrument
was compared to the Snap-A-Ray film holder. However, films taken with the
Precision instrument showed the highest frequency of improper film positioning
(28.4 per cent) of any device used (Table II). This frequency is 2.8 per cent
higher than when the XCP instrument was used, and it is 9.9 per cent higher
than when the Snap-A-Ray film holder was used. It may well be that the size
and volume of the Precision instrument, as well as its weight, are drawbacks
in the learning situation in positioning films in the patients’ mouths. Radio-
graphs made with this instrument showed 7.7 per cent frequency of horizontal
overlapping, which is comparable to that produced with the Snap-A-Ray film
holder (8 per cent) and 4.5 per cent less than that which resulted from using
the XCP instrument (12.2 per cent) (Fig. 2).
The total frequency of errors with the Precision instrument was 40.8 per
cent. However, the performance of the senior students was better (34.8 per
cent) than the performance of the junior students (46.2 per cent). A possible
reason for improvement may be that the senior students, using the Precision
instrument for the first time, had the benefit of previous radiographic training
which provided them with more skill in positioning the films. The frequency
of improper film positioning among the radiographs which were made by the
senior group was 23.7 per cent; however, the frequency was 32.7 per cent for
the junior group, a 9 per cent difference. Other than that, the errors made by
the juniors were comparable to those made by the seniors in relation to incorrect
vertical angulation, horizontal overlap, cone-cutting, and miscellaneous errors.
Regional distribution of technical errors made by the students using the
Precision instrument is shown in Fig. 4.+ The dominating error was improper
film positioning which occurred with the highest frequency in the mandibular
molar-premolar regions and the maxillary central incisor region and, to a
lesser degree, in the maxillary molar regions and the cuspid regions of both
*Since cone-cutting and incorrect vertical angulat.ion errors were minimal when the Pre-
cision instrument was used, both of these errors were added to the category of miscellaneous
errors.
Pig. 4. Regional distribution of 1,092 periapical radiographic errors made by 51 junior
and senior dental students in 173 periapical surveys when the students used the Precision
x-ray instrument.
The average numbers of retakes per periapical survey made with the XCP
and the Precision instruments were similar. Students using the XCP instrument
had 4.4 per cent fewer retakes than sbudents using the Snap-A-Ray film
holder, while the improvement was almost equal (4.7 per cent) for those students
using the Precision instrument (Table III).
It might be said that a 4.4 per cent or 4.7 per cent reduction in the fre-
quency of retakes is not a substantial improvement. However, the images pro-
duced with the XCP and the Precision instruments were of higher quality,
and with the Precision instrument the amount of radiation to the patient is
reduced.8-10 The problems of using these instruments constitute a challenge for
teachers and students.
In this study, the frequency of retakes with the bisecting-angle technique
(27.5 per cent) was comparable to that reported by BeanI (25 per cent). In
contrast, the frequency of retakes in this study when the XCP instrument
was used (23.1 per cent) was almost double that reported by Bean’l (11 per
cent). Furthermore, the frequency of retakes when the Precision instrument
was used (22.8 per cent) was also almost double that reported by Weissman
and LonghurstlZ (11 per cent).
Our data and the findings of the other two studies may be not comparable
because variations do exist between the three research designs. Moreover, the
judgment of the three observers of these studies as to what constitutes a
poor-quality radiograph and which radiographs need to be retaken will prob-
ably vary. The findings of the three studies, however, are in agreement in that
the most frequent error was improper film positioning when students used the
XCP or the Precision instruments.
CONCLUSIONS
This study was designed to explore periapical x-ray techniques for the
purpose of selecting one that reduced the number of technical errors made by
the dental students.
A total of 158 junior and senior dental students were divided into three
equal groups. Each group was assigned to use one of three devices-the XCP
instrument or the Precision instrument employing the paralleling principles
or the Snap-A-Ray film holder employing the bisecting-angle principles. The
students made 585 periapical surveys in one semester for this study.
Almost one half (49.9 per cent) of the periapical radiographs made by the
students who used the bisecting-angle technique and the Snap-A-Ray film
holder demonstrated one or more technical errors when each radiograph was
evaluated individually. The most frequent error noted was improper film
positioning (18.5 per cent). This was followed, in descending frequency, by
incorrect vertical angulation (11.8 per cent), cone-cutting (10.2 per cent),
and horizontal overlap (8 per cent). Miscellaneous errors, such as film bending,
film fuzziness, etc., constituted 1.4 per cent of the errors.
The two groups of students who used the XCP and the Precision instru-
ments demonstrated a drastic reduction in both cone-cutting (0.1 per cent and
Volume ,33 Comparison of radiographic techniques 295
Number 2
0.7 per cent, respectively) and incorrect vertical dimension of the image (1.1
per cent and 2.6 per cent, respectively). However, there was an increase in
improper film positioning (25.6 per cent and 28.4 per cent, respectively). Hori-
zontal overlapping was greater (12.2 per cent) in the group using the XCP
instrument ; horizontal overlapping was comparable (7.7 per cent) in the group
using the Precision instrument to that when the Snap-A-Ray film holder was used.
The total frequency of errors was 41 per cent for the XCP group and 40.8
per cent for the Precision group when each radiograph was evaluated indi-
vidually. This indicates that the two instruments were comparable in the
hands of the dental students and resulted in a lower frequency of errors (9
per cent) than when the Snap-A-Ray film holder was used.
When each periapical survey was evaluated as one unit, the average num-
ber of retakes per periapical survey (14 films) was 3.8 (27.5) for the group
of students who applied the bisecting-angle technique.
The average number of retakes per periapical survey (16 films) was 3.7
(23.1 per cent) when the XCP instrument was used and 3.6 (22.8 per cent)
when the Precision instrument was used. This, again, indicates that these two
instruments were comparable in the hands of the dental students, and there were
4.4 to 4.7 per cent fewer retakes than when the Snap-A-Ray film holder was used.
It has been reported that with the Precision instrument there was less x-ray
exposure to the patient.*-lo On the other hand, this instrument frequently was
not well tolerated by the patient, probably because of its inflexible metallic
nature.
It is our observation that the radiographs made with the XCP and the
Precision instruments were of higher quality. Accordingly, if either should be
the instrument of choice, the problems of their use, which are improper film
positioning and horizontal overlapping, constitute a challenge to both teachers
and students for future improvement. Hopefully, the frequency of these two
errors could be reduced to a more acceptable level.
REFERENCES
1. Mourshed, F.: A Study of Intraoral Radiographic Errors Made by Dental Students. Oral
Surg. 32: 824-828, 1971.
2. Updegrave, W. J.: New Horizons in Periapical and Interproximal Radiography, Elgin,
Ill., 1967, The Rinn Corporation, pp. 2-38.
3. Medwedeff, F. M., and Elcan, P. D.: A Precision Technic to Minimize Radiation, Dent.
Survey 43: 45-53,196i’.
4. Medwedeff, F. M., Knox, W. H., and Latimer, P.: A New Device to Reduce Patient
Irradiation and Improve Dental Film Quality, OR& Sm. 15: 1079-1088, 1962.
5. Weissman, D. D.: Manual of Rectangular Field Collimation for Intraoral Periapical
Radiography, Los Angeles, 1970, School of Dentistry, UCLA.
6. Updegrave, W. J.: Simplifying and Improving Intra-oral Roentgenography, ORBL SURQ.
12: 704-716, 1959.
7. Updegrave, W. J.: Higher Fidelity in Intraoral Roentgenography, J. Am. Dent. Assoc.
62: l-8, 1961.
a. Winkler, K. G.: Influence of Rectangular Collimation and Intraoral Shielding on Radia-
tion Dose in Dental Radiography! J. Am. Dent. Assoc. 77: 95-101, 1968.
9. Weissman, D. D., and Sobkowskl, F. J.: Comparative Thermoluminescent Dosimetry of
Intraoral Periapical Radiography, 0~ BURG. 29: 376-386, 1970.
10. Weissman, D. D., and Feinstein, R. B.: X-ray Beam Profiles and Oral Radiography,
OUL SURQ. 31: 546-555,197l.
296 Mourshed and McKinney Oral Surg.
February, 1972