Occlusal Film Exposures for the Child Patient
July/August 2007
Beverly J. Kennedy,RDH, MA
Contemporary Dental Assisting
Abstract
It is not unusual to have parents call the dental office stating that their 5- or 6-year-old child has new teeth coming in behind his or her baby teeth. For these young patients, occlusal radiographs are more easily exposed than periapical radiographs by using the maxillary and mandibular occlusal techniques. With occlusals, no film touches the floor of the mouth or the hard palate, and no film holder is required. As such, the gag reflex is not initiated and the tongue doesn't push the film out of the mouth, as so commonly occurs with other intraoral exposures on small children. In addition to evaluating growth and development, an occlusal exposure is indicated for pediatric patients presenting with anterior trauma, a supernumerary tooth, suspected pathology of erupted deciduous and unerupted permanent teeth, or a central tooth fused to a lateral tooth. Modification of these techniques can be used to expose canine periapicals using size 2 film for adolescent patients. This article will discuss the advantages of using the maxillary and mandibular occlusal techniques to radiograph anterior areas for pediatric patients and illustrate the technique so the reader will be able to easily expose these radiographs.
Film placement for anterior periapicals of children and adolescents can be very difficult. It is often impossible for small children to tolerate the film on their oral mucosa or the weight of the film holder. Their tongues often prevent film placement and, when the film touches the oral mucosa, the gag reflex is initiated. Maxillary and mandibular occlusal film techniques provide an easy alternative for both the patient and operator.1 With these techniques, children only need to bite or occlude on the film. In addition, size 2 film is used, which can capture a much broader area than the size 0 or 1 film traditionally used for periapical exposures. These exposures can be made using digital radiography as well; size 2 sensors and imaging plates can be positioned easily in the same way as size 2 films.
Mandibular Occlusal Technique
As part of the examination of the young patient with permanent teeth erupting lingual to retained deciduous teeth (Figure 1), a radiograph of the lower anterior region is indicated. Exposing an occlusal film will provide more coverage of this region than a periapical image and will be much easier for the patient.
Exposing Mandibular Occlusal Films
* Position the child upright and use size 2 film.
* For a child younger than 6 years of age, decrease the exposure time by one fourth to one third of the exposure time used for adults.2-4
* Allow the child to hold the film, explaining you are going to use it to take a picture of their front teeth.
* Place the lead apron.
* If this is the child's first time having radiographs, it is important to show the child the camera or tubehead.
* Before placing the film, align the tubehead. Center the collimator under the chin at -55? vertical angulation.3 Direct the horizontal angulation between the centrals. It may be necessary to ask the child to tilt his or her chin up to adjust the collimator correctly.
* Position a size 2 film horizontally across the lower arch with the white side down (Figure 2). Tell the child you need them to bite softly or gently, otherwise they may bite through the film packet. The collimator should cover the entire film and remain at -55? vertical angulation (Figure 3).
* Tell the patient they must sit very still while the button is pushed. Figure 4 shows a resultant occlusal radiograph. If the teeth appear as pegs and no tissue is seen lingual to the lower anteriors, too much negative vertical angulation was used. The central ray (middle of the collimator) should not strike the film at 90?.
Maxillary Occlusal Technique
Upper permanent centrals do not often erupt lingual to deciduous centrals, but radiographs exposed using the maxillary occlusal technique can be used to evaluate crowding, growth, and development in a transitional dentition, just as they are used for lower occlusals. For example, Figure 5 shows a mesiodens erupted between the deciduous maxillary centrals in a 6-year-old child. The area was radiographed using the maxillary occlusal technique and the resultant radiograph is shown in Figure 6. However, radiographs made using this technique are more apt to be used to evaluate the extent of trauma following bicycle or swimming accidents affecting newly erupted upper centrals. Again, this is an easy exposure; the film does not impinge on any soft tissue.
Exposing Maxillary Occlusal Films
* Position the child upright with the occlusal plane parallel to the floor and use size 2 film.
* For a child younger than 6 years of age, decrease exposure time by one fourth to one third the exposure time used for adults.2-4
* Place the lead apron.
* Place the top edge of the collimator above the eyebrows at 60? vertical angulation. Direct the horizontal angulation between the centrals.3
* Position size 2 film horizontally with the white side toward the upper arch, facing the collimator (Figure 7). Tell the child to bite softly or gently to hold the film stable.
* Tell the patient to sit very still and expose the film. If the teeth appear elongated, more vertical angulation is needed or the child is not positioned correctly. If teeth are foreshortened, less vertical angulation is indicated.
Canines
Often periapicals of deciduous canines need to be exposed for the older pediatric patient before the initiation of orthodontic therapy. However, the shallow palatal vaults of these patients make it difficult to position film holders. An alternative to these periapical exposures is modifying the occlusal techniques for maxillary and mandibular canines. Modification allows use of size 2 film, which captures a much broader area than the size 0 or 1 films typically used for these exposures. The film should not impinge on any tissue on the floor of the mouth, the tongue should not push the film out, and the gag reflex should not be initiated, because the film does not contact the oral mucosa. In addition, no film holder is needed, which often makes the patient more cooperative. This modification also can be used to expose periapicals of laterals or centrals on an older child if a film holder cannot be positioned.
Modification of the Occlusal Technique to Obtain Maxillary Canine Periapicals
* Position the patient upright and place the lead apron.
* Use size 2 film.
* Preset the tubehead at approximately 60? vertical angulation.
* Position the film lengthwise, and center it on the canine with most of the film inside the mouth (Figure 8). Have the patient bite gently. The white side of the film faces up toward the maxillary arch.
* Direct the horizontal angulation to the middle of the canine or at the ala of the nose (the flaring cartilaginous process forming the outer side of each nostril), making sure the film is centered in the collimator. The upper edge of the collimator should be near the patient's eyebrows (Figure 9).
* Expose. Figure 10 was obtained using this technique.
Modification of the Occlusal Technique to Obtain Mandibular Canine Periapicals
* Position the patient upright and place the lead apron.
* Use size 2 film.
* Preset the vertical angulation at -45?.
* Place the film lengthwise over the lower canine with the white side of the film toward the mandible. Tell the patient to lift the chin slightly. Placing a sticker or picture on the ceiling will give the patient a place to focus.
* Direct the horizontal angulation at the center of the canine. The film should be centered in the collimator. The film should be entirely covered by the collimator and the vertical angulation remains at -45? (Figure 11).
* Expose. Figure 12 was obtained using this technique. If the resultant radiograph appears foreshortened (Figure 13), too much negative vertical angle was used; the central ray entered the film at 90?.
Other Uses
Occlusal films are included in the Guidelines for Prescribing Dental Radiographs for the child patient with a transitional dentition (deciduous dentition present with first permanent tooth erupted).5 These films are part of the recommended radiographic examination for the new patient to assess growth, development, and dental diseases as an alternative to periapicals and in addition to a panoramic examination and posterior bitewings.5
Occlusal films do not have to be taken in pairs, but should be exposed whenever conditions warrant their need. If films are needed of the entire dentition for a child 3 to 6 years of age, maxillary and mandibular anterior occlusals and a posterior bitewing on each side (size 0) are indicated.1 By exposing the occlusal films first, the child experiences a good introduction to "taking pictures." These films are easily obtained and comfortable. Then, taking bitewing exposures should be easier because of the confidence gained with the first films.
Most often occlusal exposures are needed for young children 3 years of age and older. However, the techniques can be used in younger children. The youngest patient the author has exposed occlusals for was a toddler who at 17 months of age presented with no deciduous teeth. The mother was very concerned if the child was going to get teeth. Because the child was so small, size 1 films were placed horizontally for both upper and lower anterior occlusal exposures. The same vertical angles of 60? for the maxillary and -55? for the mandibular were used and the exposure time was lowered to one half of the time used for adult exposures because of the child's age and size. The toddler sat on her mother's lap with the lead apron placed over both of them. Although the toddler cried and moved during the film exposure, the processed films (Figures 14 and 15) readily showed the presence of both deciduous and permanent teeth indicating the child was slow in eruption.
Figure 14: Resultant image using size 1 film and upper occlusal technique for a 17-month-old child.
Figure 15: Resultant image using size 1 film and lower occlusal technique for same patient. Even though image is blurred because of patient movement, the unerupted teeth are readily displayed.
Conclusion
Anterior occlusal radiographs are easily exposed for children and provide ample coverage of areas of concern. For patients presenting with trauma, suspected pathology, supernumerary teeth, or concerns of growth and development, these exposures provide an accurate record of the areas in question and a pleasant dental experience for young patients and dental radiographers.
References
1. Johnson O, Thomson EM. Essentials of Dental Radiography for Dental Assistants and Hygienists. 8th ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2006:312-313.
2. Miles DA, Van Dis ML, Jensen CW, et al. Radiographic Imaging for Dental Auxiliaries. 3rd ed. Philadelphia, Pa: WB Saunders; 1999:131-135.
3. Haring JI, Howerton LJ. Dental Radiography Principles and Techniques. 3rd ed. St. Louis, Mo: Saunders; 2006:289, 295.
4. Langland OE, Langlais RP, Preece J. Principles of Dental Imaging. 2nd ed. Baltimore, Md: Lippincott Williams and Wilkins; 2002:131-132.
5. Public Health Service, US Food and Drug Administration, American Dental Association Council on Dental Benefit Program, Council on Dental Practice, Council on Scientific Affairs. The Selection of Patients for Dental Radiographic Examinations. Washington, DC: US Dept. of Health and Human Services; 1987. Revised 2004.
 |
jswerdlin says: | 2012-02-06 10:09:21 |
| I am in the animal field. We are trying to take dental films og dogs and cats while they are awake. I know this has to be possible. Im looking to the pediatric field for insight. Any advice would be great! | ||
Comments: 1