hi everyone this is Miss O'Brien in this presentation we are going to review chapter 21 from your dental radiography principles and techniques textbook and this is the chapter on the bite Wing technique okay so our objectives for this lesson are to Define key terms associated with the bytewing technique describe the purpose and the use of the bytewing image we're going to describe the appearance of opened and overlapped contact areas on a bitewing image we're going to State the basic principles of the bite Wing technique we're going to list the two ways a receptor can be stabilized in the bitewing technique and identify which one is recommended for bite Wing exposures we are also going to list the three receptor sizes that can be used in the bitewing technique and identify which size is recommended for exposures in the adult patient and we're going to describe correct and incorrect horizontal angulation and lastly we're going to describe the difference between positive and negative vertical angulation all right let's get started all right so we have talked about lightwing radiographs previously uh in last week's lecture so there are two types of bitewing radiographs I didn't tell you guys this last week because I wanted to save it for a surprise so here it is I know you've been you're so excited so um so there's two types of lightwing radiographs we have horizontal which is here pictured on the left I'm circling that with my cursor and then we have vertical right so the only difference between horizontal and vertical is that you turn the film The film's rectangular or the sensor whatever you're using it's a rectangular shape right so if you have it horizontally in the mouth you get a horizontal by Wing if you turn it to a vertical orientation then you get a vertical bite Wing so um so with most patients a lot of younger patients you'll be taking horizontal by Wings right because remember we said that bite Wings we use them to the look between the teeth for any Decay or cavities or anything like that but we also use them to look at the bone levels around the teeth right so you can see the bone levels this person has diminished bone levels this person I probably would have taken a vertical radiograph one that on them because they do have periodontitis now the vertical the vertical images we take those on patients that have periodontitis because if you look at this patient this patient has severe bone loss on the right you know their two teeth may even be loose if we turn this you know the other way and took a horizontal image on this patient we might not be able to see where the bone levels were you know the image might cut off like right along here and then the bone levels are up here and we're just left wondering you know how much bone have they lost well you don't know you know because you don't you don't have X-ray vision and if you took a horizontal bite wing it just might might have cut off and you wouldn't have seen you know the actual bone levels so so horizontal bite Wings generally we take those on younger healthier patients vertical bite Wings we usually take those on older patients that may or may not have periodontitis or a predispit predisposition to periodontitis so these are your two types of bitewing radiographs horizontal and vertical okay what we're talking about all right so bioing x-rays are not the same as periapical x-rays right we talked a little bit about that in the previous um week previous module so here are your periapical x-rays so periapical Perry means around and apical means the Apex or tip of the root right so with the periapical X-ray we do want to see the entire crown of the tooth all the way to the root of the tooth plus two to three millimeters beyond that um you know this is different than the bite Wing x-rays bite Wing x-rays we're seeing the maxillary teeth and the mandibular teeth on one image so here's a periapical of the anterior teeth these are your um your top front teeth you know your anterior teeth and then here's a periapical image of the molars and the premolar here so these are your periapical images you see the crown the root beyond the root of the tooth only from one Arch the lower teeth or the upper teeth not both and then then the bite Wings just to remind you we're seeing the crowns of both the um the maxillary teeth or the upper teeth and the mandibular teeth or lower teeth we're seeing those on one image okay all right so just real quick if you see do you guys see these little Tails here like coming off the tooth you can see them there you can see them here here you guys may or may not know what that is that's called calculus or tartar that's plaque that that hardens on your teeth from minerals sometimes you can see it on people's front teeth if you the lower front teeth if you look real close but but that's something that needs to be scaled off you know that's going to cause disease cause inflammation in the gums and then you can see this this is probably the third molar here it kind of is tilted forward the person is missing their second molar so um so that's you know they have a little bit of a dentulous area there so these are your bite Wings maxillary and mandibular crowns on one image and then here are your Perry apicals which show the entire tooth from the tip of the crown to the tip of the root okay we're not talking about Pas this lesson is just on bite wings so we're not actually talking about periapical x-rays in this lesson okay so why do we expose bite Wing radiographs so again we went over this last module they're also called interproximal radiographs and inner proximal is the area between the teeth right so these may be taken the loan or in conjunction with a full mouth series of radiographs so usually you take a full mouth series about every three years again it depends on the needs of the patient and then you take bite Wings about every year but again it depends on the needs of the patient so bite wings are ideal for examining Dental caries on proximal surfaces of teeth so this is where the adjacent teeth contact each other in one Arch so we're looking for dental caries between the teeth so when we say proximal surfaces are in our proximal area we're talking about here and here and here and here you have this enamel layer on the teeth right and that's where the cavity is most likely going to start or the Decay so um so we're looking in this this proximal area or in our proximal area and then we're also looking at the bone levels so okay um so bite Wings reveal carries um carries is actually the the proper term for Decay you'll hear it called Dental caries or carries um carries the word carries is actually singular and plural you wouldn't have a dental carry you you always have dental caries that's actually the singular and the plural so it's a little bit weird so bite Wings reveal Dental caries in the very earliest stages when remineralization treatment is still possible so what happens when you um when you have Decay when you form Decay between your teeth or dental caries between your teeth it starts off as a very small lesion and at that point if you catch it early enough you can re-mineralize it with treatments like fluoride for example so if again we'll go back to this bite Wing here if if you were to see a just a very small cavity between the teeth on the X-ray and it's not too deep into the enamel you know maybe you could remineralize that so so what we do you know we take these x-rays because we want to see the cavities very very early on so that we can try to fix them you know hopefully without a filling or get a small filling in there if if you don't have these bite wing radiographs for a long time you know you might never see the cavity or the the dental caries it could progress into the tooth and if it gets into this area of the pulp then you know you're going to need a root canal that could be a real problem so we want to catch the cavities when they're very very very small we can't see them with the naked eye we have to detect them on these these radiographs if you can see a cavity in the tooth with your just looking you know visually with the naked eye then that cavity has destroyed a lot of the tooth and it's really you know there's going to be a large restoration or crown involved so so we take these x-rays so we can catch these things very very early before too much destruction of the enamel and other tooth structures take place right so um so the advantage of bitewing radiographs over periapical radiographs is that bite Wing radiographs they show the height of the alveolar bone Crest and interproximal Decay or carious lesions better than periapical radiograph so so yeah on periapical radiographs you can see between the teeth to some degree and you can see the bone levels but it's not the same as with the bite radiographs the bite Wing radiographs really give you a better image of the you know of the bone and the areas between the teeth so you can catch Dental caries earlier okay and that's very important all right so bite Wing technique so again here's another set of bite wings um not not a great set so if you look at this you know this is the right side of the mouth if you look at the right molar bite Wing look at all that overlap look at all that overlap there is no way that you would be able to diagnose Dental caries between those teeth because you can't see what's going on you know if you look at the lower lower teeth you can see here's the enamel layer here here's the enamel layer here you know if this was bigger you could see those areas very well but when you have this much overlap that's not Diagnostic and then if you look over here it looks like something happened here this is called a cone cut but if you look here we can't see the bone levels between the teeth so we don't really know where the bone is so you can see them a little bit on this radiograph but you know it's it probably would have been helpful to have a vertical bite wing for this person honestly so by Wing technique bite wing image examines the interproximal surfaces of the teeth so again the area is between the teeth is what we're you know mostly interested in what the clinician sees we'll see the crown of the maxillary teeth the upper teeth and the mandibular teeth the lower teeth and the inner proximal areas and crustal bones so between the teeth and then this this bone this alveolar or crustal bone we call it the purpose of the bitewing radiographs is to detect interproximal Dental caries or Decay especially for early carious lesions that are not clinically evident so when we say not clinically evident that means when the patient opens their mouth and we look in the mouth we can't see it right you you can't see between the teeth like this when you just look in the person's mouth even if you're wearing like you know magnifying glasses you can't see between the teeth without taking a radiograph so that's why we need these um so the bytewing radiographs also assess existing restoration and levels of crustal bone between the teeth so when we look at the alveolar Crest or the crustal bone between the teeth we want to look at the level of it you know are they missing a lot of bone um you know do they have periodontitis or do they have healthy bone levels then we also look at existing Restorations so if you look at this molar this mandibular molar you can see this has a big filling in it okay that's probably a big silver filling and amalgam filling sometimes these fillings um when they break down decay can form around the filling so you might see Decay like under the filling we call that recurrent Decay so again we're looking at that when we take these these radiographs you know we're evaluating those areas too so again the bite Wing technique is also known as the interproximal technique which means between two adjacent tooth surfaces so it's where the teeth meet we're especially looking there okay so let's just talk about some terminology real quick inner proximal means between two adjacent surfaces or two surfaces that are next to each other uh enter proximal examination this is intraoral examination used to inspect the crowns of both the maxillary and mandibular teeth on a single image so that's also called a bitewing examination okay and then bite Wing receptor this is a type of receptor used in interproximal examination the receptor has a wing or tab that the patient bites down on to stabilize the receptor so so if you're just using a bitewing receptor with no aiming Rings you stick you know it's either a cardboard or plastic Wing adheres to the the sensor and the patient bites down on it and we'll see pictures of all this alveolar bone this is a bone that supports and encases the roots of the teeth so here's your alveolar bone this bone around the teeth you can see it between the roots you can see it between the teeth that's your alveolar bone and then when we talk about the crustal bone this is the coronal portion of alveolar bone found between the teeth which is also known as the alveolar Crest so when we say coronal that means Crown okay so crowns of the teeth that's all also called coronal so um when we talk about coronal the coronal portion of the bone that's here closest to the crown of the tooth okay so we we call this crestal bone this is the the alveolar Crest this is the alveolar bone and the crustal bone is the one that's the part that's closest to the crown of the tooth okay um and then contact areas this is the area of the tooth that touches the adjacent tooth so let's go back again this is a contact area the two teeth touch this is the contact area this is the contact area this is the contact area so it's where the two teeth touch or you know are adjacent um horizontal bite Wing the receptor is placed in the mouth with the long portion and a horizontal Direction and then the vertical bite Wing is just when you flip it and the long portion is in the vertical Direction so we saw pictures of both the horizontal bite wing and the vertical bite wing and remember the vertical bite Wing is used on patients that either have periodontal disease or may develop periodontal disease it's better for seeing bone levels the the crustal bone levels okay open contacts these appear as a thin radiolucin or black line between adjacent tooth surfaces and overlap contacts this is the area where the contact area of one tooth is superimposed over the contact area of an adjacent tooth so let me show you again this is an open contact this is an open contact this is an open contact this is an open contact here I'm circling with my cursor that's overlap right that's severe overlap this is overlap so that's a non-diagnostic image okay and that's it for terminology let's move along all right so principles of the bite Wing technique the receptor is placed in the mouth parallel to the crowns of both the maxillary and the mandibular teeth so the receptor just goes on the you know the tongue side of the teeth basically and is parallel to the crowns of both the maxillary and mandibular teeth the patient bites on the on the bite Wing tab you know that's your little bite Wing tab there or the the block of the beam alignment device so this is actually part of the block of the beam alignment device but you know this is the the tab and you can see over that here she doesn't have a bean beam alignment device but she's biting on the little tab or the wing um the central x-ray beam is directed through the contacts of the teeth using a vertical angulation of plus 10 degrees so when you talk about vertical angulation you know it's whether the pit is pointing up towards the ceiling or down towards the floor that's your vertical angulation so um so when you're taking uh bite Wings the the pitch should be pointed just a tiny bit downward and that's plus 10 degrees that's what it's considered and we'll we'll go over all that all right okay so here's um positive vertical angulation is when the pit is pointing downwards towards the floor right not completely downwards you know at an angle and negative vertical angulation is when the PID of the X-ray unit is pointing upwards right so um so zero vertical angulation was is when it's completely flat and when you're taking bite Wings you want it to be at plus 10 so plus vertical angulation is pointed downwards minus or negative vertical angulation is pointed upwards so again when we take bite Wings we want a vertical angulation of plus 10 degrees so that's what this says so it's just very very slightly pointed downwards when you take the bite wings okay so the bite Wing uh we want positive 10 degrees vertical angulation so here's your PID and that's the part that goes against the patient's cheek let me just show you here's your PIN right and um so the the X-ray beam comes out of the center of the pit and it comes out in a very straight line so you want to line the pin up a pit up so that it's plus 10 degrees to the horizontal occlusal plane so where the patient bites together um so here's the byte tab this is the image receptor so this is either the film or the sensor if you're going digital and and you connect a tab to that and the patient bites on it between their teeth right so the sensor is parallel to the crowns of these teeth this is parallel right and then you have that plus 10 degrees of angulation so this drawing in real life looks like this right so she's biting the sensor is parallel to her teeth on the on the tongue side or the lingual side and she's biting on the tap and then the pit is at plus 10 degrees angulation vertical angulation okay so um the bite Wing beam alignment device so this is what the bite Wing beam alignment device uh looks like it consists of the image receptor holder so the image receptor this is your film or your sensor uh the image receptor holder um you know your film Just Clips into there or your sensor and then this is The bitewing Bite Block and then attach The bitewing Bite Block is the positioning arm and the aiming ring so you put this all together you have the patient bite down on this and you line up the PID with the aiming ring so it's kind of like training wheels really um you know and most people use these all the time they they don't ever stop using them um okay so um so the bite Wing beam alignment device holds the film or sensor in the map and maintains position throughout the Imaging procedure so once the patient bites down on this securely it stays in place you know unless they open their mouth or you know do something like that it's going to stay in one place and it's very secure so with the bite Wings the it's usually color coded red you know when you see red that means it's a bite Wing holder use the Rin xcp extension cone paralleling system so so Rin is one of the brands you know of of these xcps and this you know when you're using this you're using a paralleling technique um this includes the red aiming ring the metal arm the red plastic Bite Block and The Bite Block can be used for vertical or horizontal so so this this film is in a horizontal position okay with this you're going to be taking horizontal bite Wings if this was flipped so that the long side was up and down that would be vertical bite wings so you actually need a different light block to take vertical bite Wings than you do to take horizontal bite wings now this this is reusable so what we do is we put this in a bag and we sterilize it in the autoclave after each use because this part goes in the patient's mouth and you might be touching this part and have saliva on your hands um and then the rectangular collimator is recommended to reduce radiation exposure to the patient so we talked about the rectangular collimator in module one and you can retrofit that to the PID but it does make it more challenging to get a good image so um you know so some people choose not to use it because of the number of retakes okay so this is what the um the bite Wing beam alignment system or device looks like and this is a Rin xcp system so this is what's very very commonly used so here um you have the the aiming ring right you have the um the rod the metal rod that holds the um The Bite Block to the the aiming ring and then here they have a film so this film is placed in a horizontal orientation they have other types of holders where you can turn the film in a vertical orientation but you'd have to change this part out so so red means bite wings okay and you can see the the film or the sensor Just Clips in this part it's very easy to do okay now back in the old days when when film was used sometimes they would use these paper bite Wings tabs and you can see this is a little more challenging because you have no aiming ring you know the patient bites down on here and then you just kind of have to figure out where that PID lines up you know so so this can lead to a lot of Errors if somebody's not experienced so so sometimes they they still use these and there are tabs that can be used for digital sensors as well um but but again no aiming rings so it's a little more challenging um you would use a paper bite Wing tab or paper bite loop on the film or sensor when it's not possible to use a beam alignment device you know sometimes you have to use these in children examples include when exposing bite wings or children or adults with small mouth or patients that are unopened unable to open wide enough so so getting all this in the mouth is is more challenging than getting just this in the mouth but again lining up the pit is going to be harder so with this the paper tab attaches to the film or the sensor either with an adhesive backing like you hear it see here you just stick it to there and it just sticks or it will loop around the film I don't like these paper Loops because they don't hold the film in place the film can slide back and forth and if it slides in One Direction or another you can get a surprise when you get your you know image and say oh it's slid and I didn't get what I needed to get so that's a problem okay so you want to attach the paper tab to the white side of the film or the side of the sensor without the cord if you have the film or the sensor in backwards you won't get well with the sensor you won't get any image with the film you won't get a good image so you always want to have the correct side of the film or the sensor towards the pit placement in the oral cavity the patient bites down on the paper tab once the film or sensor is inserted between the tongue and the teeth so so this the film goes between the tongue and the teeth and then this the patient bites down on they bite their teeth together and this will be between the teeth and if you can't visualize that very well don't worry we're going to practice it a lot all right so bite Wing receptors and film sensor size so um so there's various sizes of film sensors because you know if you're dealing with Excuse me a very small child versus a large adult you would need a different size sensors for them so so the size zero this is used to examine the posterior or back teeth of children with primary dentition you know with baby teeth this is used in the horizontal Direction a typical number of exposures for kids is two bite Wings one on the right side and one on the left side again it depends on the age of the child but younger children would have two bite wings with the size zero sensor a size 2 sensor would not fit in their mouth so the size two this is used to examine posterior or back teeth and older children teenagers and adults so the size two you know it depends on the child but usually when they're you know around 10 or so the size 2 is more more appropriate so the size two is recommended size for adult patients and the size two can be used in the horizontal or the vertical Direction so you can you know flip it either way depending on if you want horizontal bite wings or vertical bite wings so the horizontal Direction This is used to evaluate interproximal carious lesions and the typical number of bite Wing exposures in the horizontal direction is four you want two two on each side two on the right side two on the left side and then the vertical Direction This is used to evaluate loss of inner Dental bone due to periodontal disease and to evaluate interproximal lesions as well so usually with vertical bite Wings you take usually two bite Wings on each side but it depends on the patient if the patient has large teeth or they have their wisdom teeth you know third molars you might need to take six bite Wings all together if it's vertical because it's not as wide as the um the horizontal image and then size three so um so size three they don't make sensors in size three but they do make films size three and the size three films are longer and narrower than size two so some offices used to use these to um to take bite Wing exposures but it's really not recommended you would use these in the horizontal Direction and it's just longer so it would get more teeth on one image but the problem was you usually got some overlap so you know so they're not typically using it so the typical number of exposures if you're using a size three is is one image on the right and one image on the left and with this it captures the the premolar teeth the molar contact areas on one single image but the disadvantages is that it's difficult to open the posterior contacts um you know there's a lot of overlap with these because of the curvature of the the jaw or the you know the arch and the crustal bone is not easily seen therefore periodontal bone loss cannot be evaluated so it's really not recommended to use a size three film for bite wings or for anything else okay so again image receptor size the size zero is used on children with primary dentition and they would use uh to get a bite Wing set of bite wings that would be two um two images one on the right one on the left and the film would be in the horizontal position and then size one there is also size One sensors um that are a little bit smaller than the size two so these are used for a child with primary or mixed dentition they would take two horizontal bite Wings in the posterior for that size one can also be used on adults for carries detection or the presence of periodontal disease again that would be an adult with like a much smaller math that couldn't tolerate the size two so you can do three or four vertical anterior periapical images with the size one and then size two this could be used you know again on the size it depends on the size of the child you can use it on children with mixed dentition prior to the eruption of permanent second molars you know that's before the child turns about 12. so you could use size two to take two horizontal bite Wings you could use them on adolescence to do four horizontal bite Wings you know two on each side if they have their second molars and then you can use it in the horizontal position to take adult bite wings or if the adult has periodontal disease you can use the size 2 sensor in a vertical position to take four vertical bite wings okay so that answers the question what size receptor should I use honestly you're not going to have a lot of choices you know probably in in your office you're going to have one size two or a couple of size two receptors or sensors and then a size zero or a size one so basically you'll have one receptor for children one receptor for adults that's what I've found okay so position indicating device angulation um so with bite Wings the angulation of the pit is critical this determines the alignment of the central Ray of the X-ray beam so remember the PID is the opening that's what goes against the patient's cheek when you're taking the um the images so so the way you have the pit angled um it's really important that you angle it correctly so you don't get overlap or elongation or for shortening which we'll talk all about those the central x-ray beam the central Ray of the X-ray beam comes out of the center of the pit so we need to make sure that we have it aligned correctly horizontal plane angulation this is modified by moving the PID in a horizontal Direction so that's to you know towards the left or towards the right it's a side to side thing we talked about the vertical plane angulation with that you're moving the pit up or down so you're pointing it either more towards the ceiling or more towards the floor the horizontal angulation you're pointing it more towards you know the front of the patient's head or the back of the patient's head that's your horizontal angulation and then position and placement of the red aiming ring guides and determines the proper PID placement and angulation so when you're using these aiming Rings you're lining the pit up with the aiming ring for the most part and that gets you in the ballpark of where you need to be as far as your horizontal angulation and your vertical angulation um failure to Center the PID and the X-ray Beam on the receptor results in a partial image or a cone cut which is non-diagnostic so we're going to go over this more you know I know it might be a little fuzzy at this point so let's go over it okay so this is your pit this is the part that goes you know against the patient's cheek that's the part of the X-ray unit that you know the the central beam the x-rays come out of here so the x-rays or the central beam comes out of the pit in a straight line right so we want that that beam to go straight through the teeth right and that's how we get these nice open contacts like we see over here we've got some great open contacts here there's there's no overlap or maybe just a smidgen there so so in order to get these open contacts that Central Ray has to go straight through those openings of the teeth you know if they come through at an angle like this or an angle like this then and that's going to result in overlap so correct horizontal angulation the central array that's these blue lines it's directed perpendicular to the teeth so it goes through the teeth through the contact areas allowing the contact areas to be open and visible okay so the receptor or the sensor that's parallel to the teeth teeth are here receptor here that's considered parallel the central beam is perpendicular to the teeth and the sensor so we want that that perpendicular angle incorrect horizontal angulation results in overlapped or unopened contact areas and this requires a retake because it's not you know they won't be diagnostic if you can't see this enamel layer clearly like we can here and here and here then it's going to be non-diagnostic okay so so what we want is for the receptor and the teeth be parallel to each other and then the central Ray coming out of the pit is going to be perpendicular and we want the central Ray directed right through these contacts so we get a nice open contact and this is why we have to in order to get open contacts we have to take two images you know this is why those long size three films are not good because there's this curvature see how it's not a straight line it curves around so the molars and if you take one image of the molars and the central Rays go straight through there but if you're trying to get the molars and the premolars on the same image the you know if the pids Align so that the the central ray goes straight through here it's not going to go straight through here you're going to get you know you're not going through the contacts you're cutting it off so you're going to get overlap in that area okay so here's open contacts this is the key to success this is what you want you can see the enamel layer you would be able this image is a little fuzzy but you know you would be able to see if there was the beginnings of any Decay or dental caries between the teeth with something like this okay here's more open contacts this is good see this right here that's a that's a cavity or a dental caries that's Decay and you can see the Decay has gone through the enamel layer and now it's in the inner layer of the tooth the Dentin so so that's a problem that needs a filling and then this is you know more open contacts so this these are you know that's what you want that's what you get when you align that Central Ray going right through the contacts of the teeth more open contacts okay so open contacts we see just a little tiny bit of black this is a smidgen of overlap but when you have an open contact you can see a little bit of a black line between the teeth but you can see this entire enamel layer and these you know these are terrific okay overlap look the sky was made very very sad that these these x-rays are so terrible with their overlap can you see see the overlap overlap overlap overlap overlap here's an open contact so they got one open contact out of you know or two here's another open contact but there's a lot of overlap right there's no way you could tell if there was a cavity between those teeth unless it was huge so um now this one uh you know here's here's a nice open contact this is a little bit open but this is overlap overlap overlap so so these are non-diagnostic the um the dental healthcare provider would have to go back and retake these X-rays and expose that patient to more radiation and we want to avoid that okay these are really overlapped like I mean how many teeth are there you can't even tell right so so this is a lot of overlap this is not diagnostic at all it just you know you would have to retake that and we want to avoid that because we don't want to expose our patients to more radiation than we have to so basically we want to you know line this thing up correctly so we get you know we get a good image so horizontal angulation okay here's your PID right and and your tube head and when we turn the PID to the left or to the right that's your horizontal angulation right if we point it up or down that's vertical angulation if we point it more to the right or more to the left that's horizontal angulation and horizontal angulation is what determines if you get overlap or open contacts okay and then vertical angulation again it's whether the the pit is pointing more downwards or more upwards you know if it's pointing more downwards you have a positive angulation if it's pointing more upwards you have a negative angulation and then what we want for for bite Wings we usually take those at an angulation of Plus 10. okay if you have the PID set at zero angulation then it distorts the tooth a little bit so we we um we have it set at plus about plus 10 usually okay um so vertical angulation uh side of the tube head so again vertical angulation is it pointing down or is it pointing up and you can see the exact number of degrees on this indicator here right so um so this looks like they have it set at positive it looks like 25 it's kind of pointing downwards a little bit so um so that would be your positive angulation so you can see here 0.25 this is 45 it's a little bit less than that like half of that okay so bite Wings again we want 10 degrees positive 10 degrees vertical angulation so it's going to be pointed downwards just ever so slightly okay um vertical angulation you know again it's whether the pit is pointing more downwards or more upwards and vertical angulation is measured in degrees and it's labeled on the outside it's two pads so again you can see it's labeled here you can see what you know whether you're doing uh how many degrees of angulation you have it may be positive or negative so when it's pointing downwards it's considered positive one is pointing upwards it's considered negative um if the occlusal PID is above the occlusal plane that means it's pointed downwards the vertical angulation is positive if the position of the PID is below the occlusal plane that means it's pointing upwards the vertical angulation is negative so when we have the vertical angulation incorrect it can distort the images so it can make the um you know it could cut off portions of the teeth or it could distort them and make them look too long or Too Short either way you can end up with a non-diagnostic image okay so bite Wings vertical angulation correct vertical angulation is plus 10 degrees pointing downwards just ever so slightly first adjust the patient's head so that the occlusal plane is parallel with the floor so you want the The Binding surface of the teeth parallel with the floor you don't want the person's head tilted downwards or Tilted upwards you know you want the straight ahead so that the teeth are parallel with the floor um so you adjust the the patient's head and you get that correct first then you go in and adjust the PID and the PID should be positive 10 degrees vertical angulation just point it downward ever so slightly okay here's what happens when you have incorrect negative vertical angulation bite Wing see how we're seeing more of the maxillary Arch and the mandibular arches cut off that's probably um it could be a couple of things but but vertical angulation would be the most likely culprit so um so this person you know they probably had this pointing downwards too much you know instead of having it positive 10 degrees angulation maybe they had it positive like 30 or something like that so you're getting much more of the maxillary Arch teeth than of the mandibular Arch teeth so this is really not diagnostic you can't see the bone levels you can sort of see between the teeth but there's you know there's some issues with this okay so why do we take bite Wings what is the rationale um so before I go over that let's just look at these pictures real quick so is this um would this take a horizontal bite Wing or a vertical bite wing if you said vertical you would be correct right because the long part of the sensor is in a vertical orientation so that's a vertical bite Wing so here we can look a little bit closer here's a horizontal bite wing horizontal bite Wing means the long part is side to side it's horizontal and then a vertical bite Wing means that the long part is in a vertical orientation so it's up and down so horizontal bytewing vertical bite Wing okay so rationale for taking bite Wings horizontal bite Wing radiographs these are used to evaluate for the presence of early interproximal carious lesions so that's Decay between the teeth this is a Decay that's not clinically visible yet we cannot see it in the mouth with just our eyes or even like magnifying glasses we need x-rays for that it's also used to evaluate margins on existing crowns and existing Restorations so if you have a filling in your tooth you could get Decay underneath the filling of the you know if it starts to break down so when we take our x-rays we can see that that's something that we would never be able to see with our naked eye but we can see that when we use x-rays and the horizontal bite wings are Exposed on young people or adults who are not at risk for periodontal disease so um so these are usually used on younger healthier people the vertical bitewing radiographs these are used to evaluate alveolar bone levels that crustal bone around the teeth as well as for the presence of early interproximalcarious lesions that aren't clinically visible yet they're also used to evaluate the margins on existing crowns and other stability of other existing Restorations so again we'll see the Restorations on the vertical bite wings and we can see if there's any Decay around them or underneath them and we usually use the vertical bite Wings on patients that are at risk for or known to have periodontal disease so the key is the periodontal disease does your patient have periodontal disease or are they at risk for periodontal disease then you use the vertical bite wings are they healthy then you use the horizontal bite wings okay so bite Wing step-by-step procedure so we want to complete our infection control procedures and gather supplies like we went over last week then we will seat the patient and prepare the patient you know we'll put um the lead vest on them and and do everything we need to prepare them uh we'll prepare the necessary equipment we'll expose the radiographs using uh definite and established order to prevent errors so you know so you want to make sure that you do you know have some sort of um system where you're not repeating x-rays accidentally right so um so it's really good on the computerized systems that we use because you can see exactly what you've taken and exactly what you need um so you just have to be careful with that so usually for bite Wings people will expose the right molar and the right premolar then the left premolar then the left molar so you just go around the mouth left to right or right to left I'm sorry but but some people will do the the premolar exposures right and left and then the molar exposure is right and left so again it just depends on the operator but just make sure you have a definite pattern so you don't have errors the number of bitewing images is taken is based upon the number of teeth in the posterior area so you know if you don't have if the person doesn't have any molars you're only going to be taking the premolar images it's not like with the periapical images where you do take images of edentulous areas the bite Wings you you only take bite Wing images if they're you know our teeth there if there's missing teeth you would take periapical images opening posterior contacts with one bite wing image on each side is impossible this is why those size three films that are very very long and try to get all the teeth on one bite wing image on each side it's you know you're going to suffer because you can't open the contacts of all the premolars and all the molars in one shot you know it's it's really difficult if not impossible um clinicians need a minimum of two bytewing images on each side right and left to successfully open the contacts so on each side we take one premolar image and one molar image clinicians may need three bytewing images on both right and left sides if the patient has third molars so this is especially true when you're taking vertical bite wings so if you look at this vertical bite Wings when you have it in the vertical orientation you're not going to get as many teeth on the image you know because it's not as wide across on the the horizontal orientation you know all the teeth will fit on there but when you have a vertical orientation you may or may not get all three molars if the person has their wisdom teeth so you have to keep that in mind okay so patient preparation for bite Wings this is procedure 21-1 in your book so we want to briefly explain the procedure to the patient you never want to just jump in and start getting in a patient's mouth without telling them what you're doing you know it's really important to inform them and then you want to adjust the chair so that the patient is positioned upright and the level of the chair is that a comfortable working height so you want to get them you know most of the chairs you can adjust the height you don't want to be bending over real far too to work on the patient so get them at a good height for you adjust the headrest to support and position the patient's head position the patient's head so that their maxillary Arch is parallel to the floor and their midline is perpendicular to the floor so basically you want the the biting surfaces of the teeth parallel to the floor you know you don't want their head pointed upwards you don't want to point it too far downwards you want it like you know so that the teeth are parallel place and secure the lead apron and the thyroid collar on the patient requests that the patient remove eyeglasses and all objects from the mouth any Dentures retainers chewing gum Etc so um you know so sometimes you can do these in a little bit different order you know some people like to as soon as they get the patient in the chair okay can you please remove your eyeglasses you know retainers Dentures whatever and then you get the patient you know in at the right height and you put it on the lead apron so just make sure you accomplish all these things but you know always explain the procedure to the patient first that should be the the first thing that you do okay um and then we want to set the exposure control factors the kilo voltage the milliamperts on the time um so again you know a lot of times there's just a button for you know an adult or a child so you know and that sets the all the exposure factors in one shot so you know you might be able to do that if a beam alignment device is used with a bitewing technique open the sterilized package containing the device and assemble the device on a covered working area so always open the package in front of the patient so they know that you're using sterilized instruments on them that will boost their confidence in you and your practice so you know so again you want to do that right before you're taking the x-rays and let the patient see you do that if a bitewing tab is used attach the tab to the white right side of the film or the flat side of the receptor if you attach it to the wrong side you won't get a diagnostic image okay so the order sequence of bite Wing exposure whether it's vertical or horizontal both apply you want to adjust the patient's head till the occlusal plane is parallel with the floor so again you don't want the patient looking up you don't want them looking down you want them looking straight ahead adjust the vertical angulation of the pin so that it's plus 10 degrees so the pit is going to be just slightly pointed downwards Place index finger on the occlusal plane and adjust the horizontal angulation and then place the receptor in the mouth without moving the pit so so again you're going to find your best way of doing this you know ultimately you want the PID at plus 10 degrees some people line up the PID early some people line it up at the last minute um you know so you might not be doing this in the exact same order um you know because placing the receptor in the mouth without moving the PID sometimes these smaller rooms you you get in there and you can't do that so uh but just make sure that the Pit's lined up at plus 10 degrees ultimately ask patient to bite on the molars you want them to to close their teeth on the holder if they just close their lips on the holder which some of them will do because it can be a little uncomfortable to bite on the holder then it's going to you know the the film's gonna or the sensor is gonna move around so and you won't get a good image so make sure that the patient is biting their teeth together and keeping them bitten together on the holder until you get the X-ray and then you want to look down the length of the PIN to make sure the receptor is covered by the opening of the pit so really if you have the aiming ring the aiming ring tells you where you know the receptor is in the middle of the aiming ring inside the mouth so you know so if you line it up with the um the aiming ring you should be good if it's not lined up then a cone cut can occur and then expose the premolar bite Wing first um then uh you know then the molar bite Wing so it just depends on your patient if your patient gags you can take the premolar bite Wings first and then the molar bite Wing second if they don't have an issue with gagging you could just take the the right molar image the right bite or a premolar image then the left premolar image and then the left molar image again it depends on your patient and your preferences as well okay so the premolar bite Wing checklist for the premolar image this is the premolar image we see the premolars for the premolar image you want the premolars visible and you want to line the the front edge of the sensor or film up with the um the canine so you want the front edge in the middle of the mandibular canine so because we want to see this contact between the canine and the premolars right so um so you line the film The Edge of the film or the sensor up with the um the lower or mandibular canine that will make the premolars visible we want the occlusal plane in the middle of the receptor so here's the occlusal plane it's the plane between the teeth so you want to see equal portions of the maxillary Arch and the mandibular Arch right you don't want to see all the way to the roots of the maxillary Arch and then have the mandibular Arch cut off you want you know equal parts maxillary equal parts mandibular um the occlusal plane is parallel with the bottom receptor Edge so you don't want the occlusal plane to be like you know angled you want it a flat line that that's parallel to the flat line of of the receptor so so you don't want this like you know point it up or point it down you want a flat line between the teeth or the occlusal plane uh correct horizontal angulation if you have correct horizontal angulation you get these really really nice open contacts um and then correct vertical angulation of plus 10 degrees that way your teeth aren't distorted you get equal parts maxillary mandibular and no cone Cuts that's what you want for your premolars then for your molars the the front edge of the receptor is lined up with the the middle of the lower uh or mandibular second premolar so these are your premolars here so you want to line up the front edge with the premolars that way you get that contact space or that contact area between the premolars and the molars you want the molars visible you want the occlusal plane in the middle of the receptor and you want the occlusal plane parallel with the bottom edge of the receptor well this doesn't do that see how the occlusal plane this line if you draw a line where the teeth meet each other the top teeth and the bottom teeth it's angled right we want that to be flat so that that's a little bit of a problem with this image you know if you look at this image the occlusal plane is parallel with the um the bottom receptor edge with this film the occlusal plane is not parallel to that receptor Edge it's a little bit angled so that you know you could you would want to correct that really correct horizontal angulation so we have that here you know we have open contacts correct vertical angulation for the most part you can see equal parts maxillary mandibular and no comb Cuts so that looks you know pretty good except for the occlusal plane okay so here we have our bite Wings model and he's showing us what it looks like when when you take bite Wings on a patient so he's got on his his lead vast and his thyroid collar very important that your patients have that on and then he's biting on The Bite Block and the receptor is inside his mouth and here's the aiming ring and you're lining it up um with the aiming ring so and then over here this is a little more challenging patients biting on a traditional bite tab for bite Wings there's no aiming ring and the operator has to line up the PID just you know by by eyeballing it basically okay um so a cone cut image here is an example of a cone cut image you get this big white portion what happens with a cone cut is that okay this is if you look at this blue outline that's your film or sensor right and your film or sensor should be completely enclosed by this red line you know when you line up the pit with the cheek it's round and then the film or sensor is square but you know if you you should take the PID and line it up so that the whole square is in the circle if they're out of alignment what you have is an unexposed area of film this area of film up here is unexposed so it's going to look white like this so that's where cone Cuts come from it's an unexposed area of the film and we will learn more about that as well but usually if you line up the PID with the aiming Rings you don't get that cone cut you know it's rare so so this whole sensor or film The PID or this part has to encircle that whole film so if you use the aiming ring it will but when you're eyeballing it like this you have to be really careful that you get this whole circle around the square you know if part of it's cut off if you're if your pit is back a little bit you're going to get an unexposed area or if it's too far forward you'll get an unexposed area and it'll look like that that's a cone cut okay so modifications to bite Wing technique a dentulous space spaces this is an area where teeth are no longer present so edentulous means that they're missing teeth this can cause a problem for bite Wing receptor placement if somebody doesn't have teeth and they bite down on the rest on The Bite Block you know it may or may not work it could you know if there's no teeth no opposing teeth then you would have a problem so what you can do to modify it if somebody is missing teeth you can place a cotton roll um in the area of the missing tooth to kind of support it um you know because you just need that support when a patient closes the opposing teeth need to occlude on the Cotton roll so if you're missing a tooth you just put a cotton roll in that area and that helps stabilize it there's something else it's called Tori these are bony growths in the mouth and tauri if they're mandibular or palatal mandibular means they're in the bottom of your mouth under the tongue or palatal means they're up on the roof of your mouth basically so bony growths can can be very difficult to work around if somebody needs bite wings so what you need to do is place the receptor between the tauri and the tongue make sure the receptor is not sitting directly on the Tory and films should not be creased to accommodate bony growth because that can ruin the film make it non-diagnostic so Tori this is a picture of Tori so this is the patient's lower jaw this was the mandible and and some people have these growths and they can be huge they could be really they can come all the way to the middle of the mouth but I have small tauri in my mouth and it would always kill me when I would have to get X-rays at the dentist because it's you know the film would cut into this part no it's just really hard to to take an x-ray and it's very uncomfortable for the patient so when somebody has Torah like that you have to place the the sensor more towards the center of the mouth so it can be kind of challenging and again it hurts the patient so um so you know that's what tour I are and they're they're benign they don't cause you know it's not like a disease state or anything but it's just uncomfortable and they just for it's like they don't know why they grow just for no reason they they occur so um you know I've had mine almost all my life that I know of and um and they don't cause any issues unless you're trying to take X-rays or if you needed Dentures or something they could cause an issue but generally they're just a benign little kind of weird thing okay so helpful hints for the bite Wing technique um set the control factors before placing the receptor in the mouth the receptor can be very uncomfortable for patients to have in their mouth so you want to do as much as you can before you place that receptor in the mouth once you get the receptor in the mouth you want to just do a final lineup of the PID and then run outside the room get the image run right back in and get that receptor out because your patients could be gagging on that it could be hurting their Tori if they have those it could be too big for their mouth kind of thing so so you want to make sure you know get everything done before you put that receptor in the mouth have the patient remove eyeglasses and all intraoral prod objects so if they have like partial dentures um you know anything like that anything metal especially could interfere with the X-ray so we want to you know just make sure the patient's not you know doesn't have dentures in isn't chewing gum uh you know tongue rings you want to get rid of those um all that stuff use a specific exposure sequence so you might want to do you know the images right to left you might want to do the premolars and the molars uh whatever you do just make sure you use a specific sequence so you're not missing images or duplicating images briefly explain the Imaging procedures you know you always want to tell the patient what you're doing and what's expected of them if you don't tell them to hold still they might not hold still if you don't tell them to bite their teeth together they might not bite their teeth together so you have to give very explicit instructions set the horizontal and vertical angulations before placing the receptor in the mouth as much as you can you know you're going to do after you get the receptor in you're going to do a final set of the PID um you know so you just kind of have to adjust it a little bit usually said the vertical angulation to plus 10 degrees direct the central Ray through the contact areas usually the aiming ring will tell you you know where to put the PID in order to do that make certain the patients remain closed during the entire exposure you know make sure they keep their teeth together not just their lips if they just close their lips around the the receptor it's going to move so they have to really bite down on that holder never use words like hurt or oops you don't want to scare the patient or make them think you're incompetent you know if you go oops they're going to be like oh my gosh what did they do wrong you know so so don't use words like that never pick up a dropped receptor if something drops on the floor it's contaminated you have to start over again you have to get all new equipment so um so if something does drop on the floor it can happen just let the patient know that you're going to wipe everything down get new holders and all that stuff you know command respect with confident technique you know kind of you guys may have heard the expression fake it till you make it um you know you're going to be really nervous when you start taking radiographs but that's okay it's okay to be nervous but you don't want to show that to the patient because then the patient will start to wonder if you're competent or not so um you know so so just try to be confident always start with the easier premolar exposure to build patient confidence so yeah you can do that start with the premolar exposures and never position a receptor on top of bone try to go around the bone so if you do the have those tauri place the receptor closer to the tongue you know around the Torah you don't want to put the receptor on top of it and that's it that's it so um so anyway a lot of this will make more sense once we start doing bite Wings in lab this is you know a great overview for you but it'll really start to come together once we get that lab time in and you guys will be picking up stuff really quickly so um well thank you for listening to this presentation and I will see you guys on campus have a great afternoon or evening